Hybrid ablation of atrial fibrillation: A unilateral left-sided thoracoscopic approach

A Hybrid Minimally Invasive Atrial Fibrillation Ablation Procedure Using Unilateral Thoracoscopy and Endocardial Pulsed Field Ablation: An Early Feasibility Study

(1) Objective: To examine the efficiency and efficacy of using endovascular mapping and pulsed field ablation in the setting of a hybrid video-assisted thoracoscopic atrial fibrillation (AF) ablation procedure. (2) Methods: Eleven consecutive patients underwent hybrid video-assisted thoracoscopic epicardial ablation and left atrial appendage exclusion followed by endocardial ablation using pulsed field ablation energy. The completeness of epicardial and endocardial lesion sets were assessed using 3D electro-anatomical mapping. (3) Results: Left atrial appendage (LAA) exclusion and durable pulmonary vein isolation (PVI) and posterior wall isolation (PWI) were achieved in all patients. The endovascular part of the necessary lesion set using PFA energy was successful in 100% of the patients. All patients remained in SR during the 12-month follow-up period. (4) Conclusions: Our study confirms the feasibility of using endovascular pulsed field ablation to complete previously performed epicardial lesion sets during the hybrid AF ablation procedures, without extending the procedure time or increasing the risk of complications.

Robotic-enhanced hybrid ablation for persistent and long-standing atrial fibrillation: Early assessment of feasibility, safety, and efficacy

Objectives

To assess feasibility, safety, and early efficacy of robotic-enhanced epicardial ablation (RE-EA) as first stage of a hybrid approach to patients with persistent (PsAF) and long-standing atrial fibrillation (LSAF).

Methods

Single-center, retrospective analysis of patients with documented PsAF and LSAF who underwent RE-EA followed by catheter-guided endocardial ablation. Postoperatively, patients were monitored for major adverse events and underwent rhythm follow-up at 3 and 12 months.

Results

Between January 2021 and June 2023, we performed RE-EA in 64 patients (73.5% male, CHA2DS2-VASc 2.7 ± 1.6, BMI 34.1 ± 6.3 kg/m2). Mean AF preoperative duration and left atrial volume index were, respectively, 85 months and 47.5 mL/m2. Through the robotic approach, the intended lesion set was completed in all patients without cardiopulmonary bypass support, conversion to thoracotomy/sternotomy, blood transfusions, or perioperative mortality. The average LOS was 1.7 days, with only 1 patient requiring intensive care unit admission and >65% of patients discharged within 24 hours. At follow-up, 2 (3.1%) patients experienced new left pleural effusion or hemidiaphragm paralysis requiring treatment. There were no readmissions related to AF, stroke, thromboembolic events, or deaths. The mean interval between the epicardial and endocardial stages of the procedure was 5.9 months. Rhythm follow-up showed AF resolution in 73.4% and 71.9% of patients at 3 and 12 months, respectively.

Conclusions

RE-EA is a feasible and safe, first-stage approach for the treatment of patients with PsAF and LSAF. It improves exposure of the intended targets, favors short hospital stay, and facilitates return to activity with satisfactory AF treatment in the short term.

Hybrid atrial fibrillation ablation

In this state-of-the art review on hybrid atrial fibrillation (AF) ablation, we briefly focus on the pathophysiology of AF, the rationale for the hybrid approach, its technical aspects and the efficacy and safety outcomes after hybrid AF ablation, both from meta-analyses and randomized control trial data. Also, we performed a systematic search to provide a provisional overview of real-world hybrid AF ablation efficacy and safety outcomes. Furthermore, we give an insight into the 'Maastricht approach', an approach that allows us to tailor the ablation procedure to the individual patient. Finally, we reflect on future perspectives with the objective to continue improving our thoracoscopic hybrid AF ablation approach. Based on the review of the available literature, we believe it is fair to state that thoracoscopic hybrid AF ablation is a valid alternative to catheter ablation for the treatment of patients with more persistent forms of AF.