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OBJECTIVE: Hybrid endocardial and epicardial ablation integrates the strengths of surgical and catheter-based approaches to ablation. However, unilateral or bilateral chest incisions are often required. We describe our experience with a novel hybrid trans-xiphoid approach to atrial fibrillation (AF) ablation.
METHODS: Consecutive patients with long-standing persistent (LSP) AF, persistent AF with significant structural heart disease, and/or prior failed endocardial ablation underwent simultaneous catheter and surgical ablation of AF using a trans-xiphoid approach. A 7 cm midline incision allowed xiphoid removal, sternal elevation, and intrapericardial access to the heart. A surgical ablation device created an antral “box” lesion anterior to the pulmonary veins and across the posterior left atrial surface. When practicable, the left atrial appendage was excluded with a clip. Immediately following epicardial ablation, an endocardial catheter ablation confirmed pulmonary vein isolation, isolation of the posterior left atrium, and created the cavo-tricuspid isthmus ablation. Anticoagulation and antiarrhythmic therapy were continued for at least 6 weeks and 3 months post-procedure, respectively.
RESULTS: Between June 2014 and November 2016, 29 patients (age 61.6 +/- 8.9, 79% male, 6 LSP, 21 persistent, 3 paroxysmal) underwent hybrid trans-xiphoid AF ablation. Comorbidities included hypertension (86%), diabetes (57%), prior stroke/TIA (14%), coronary artery disease (57%), congestive heart failure (24%). Mean (SD) CHA₂DS₂-VaSC was 2.3 (1.7), ejection fraction 55 (7) %, LA diameter 5.0 (1.0) cm, and 79% had failed 2.1 (0.7) prior endocardial ablations. Average total procedural time was just over 6 hours; Average total fluoroscopy time was 35 minutes. Complications included pericarditis (38%), transfusion (3%), acute renal insufficiency (12%), and one in-hospital mortality (3%) due to refractory vasoplegia. Median hospital length of stay was 6 days. Simultaneous LAA clipping was done in 70%. At a median follow-up of 189 days, 22 (76%) of patients remained free of AF with 24 (83%) remaining on previously ineffective antiarrhythmic drugs using continuous monitoring.
CONCLUSIONS: The hybrid trans-xiphoid AF ablation represents a novel beating-heart technique for maintaining sinus rhythm in challenging AF ablation patients.