Robotic-Enhanced Convergent Plus Procedure
Ali Syed, MS, Jacob Lindemann, BS, Benjamin Seadler, MD, Mario Gasparri, MD, Stefano Schena, MD PhD.
Medical College of Wisconsin, Milwaukee, WI, USA.
BACKGROUND: The Convergent Procedure (CP) is a hybrid strategy for treatment of long-standing atrial fibrillation (AF) combining surgical epicardial ablation, through a subxiphoid incision, with percutaneous catheter endocardial ablation. It provides higher rates of sinus rhythm restoration compared to catheter-directed ablation only. Despite its recent introduction, CP has undergone a few iterations. The most recent being the utilization of a left VATS approach in order to expand the left atrial (LA) ablation lesion set with exclusion of the appendage (Convergent Plus Procedure, CPP).We introduce technical features and clinical advantages of a robotic-enhanced CPP.
METHODS: Differently from the traditional CPP, the entire exposure of the posterior wall of the LA and pulmonary veins is achieved in a thoracoscopic fashion rather than through subxiphoid cut-down with restrictive vision mandated by a pericardioscopy obturator. Ultra-magnified operative field and robotic arms maneuverability allow full visualization of the LA posterior wall and pulmonary veins, minimal interference from the anterior pericardial reflection and precise positioning of the epicardial ablation catheter. The risk of LA injury is also minimized when not introducing a traditional bipolar radiofrequency clamp. Such approach facilitates division of the ligament of Marshall, creation of the entire posterior wall box lesion set, bilateral semi-circumferential ablation of the pulmonary veins, creation of the LA appendage isthmic lesion and appendage exclusion by external clipping. The robotic-enhanced CPP offers additional advantages such as minimal postprocedural discomfort, hospital stay <24h, decreased risk of wound complications and prompt resumption of physical activity.
RESULTS: We have successfully utilized a robotic-enhanced CPP in our institution since 2019(n=56) with no intra- or perioperative complications. The procedure has resulted in a significant appeal to patients and referring physicians. This video provides a step-by-step description of the proposed modifications in comparison to the traditional CPP. It also highlights critical anatomy exposure, the expanded ablation lesion set performed and its clinical advantages.
CONCLUSIONS: Robotic-enhanced CPP represent an innovative and highly attractive alternative for patients with long-standing AF. Further studies with appropriate follow-up are needed to verify its long-term efficacy in the management of long-standing AF when compared to current medical, surgical and catheter-related treatment options.
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