Simultaneous catheter and epicardial ablations enable a comprehensive atrial fibrillation procedure

ArticleinInnovations Technology and Techniques in Cardiothoracic and Vascular Surgery 6(4):243-7 · July 2011with55 Reads
DOI: 10.1097/IMI.0b013e31822ca15c · Source: PubMed
Abstract

Transmural and contiguous ablations and a comprehensive lesion pattern are difficult to create from the surface of a beating heart but are critical to the successful treatment of persistent, isolated atrial fibrillation. A codisciplinary simultaneous epicardial (surgical) and endocardial (catheter) procedure (Convergent procedure) addresses these issues. Patients with symptomatic atrial fibrillation who failed medical treatment were evaluated. Using only pericardioscopy, the surgeon performed near-complete epicardial isolation of the pulmonary veins and a "box" lesion on the posterior left atrium using unipolar radiofrequency ablation. Simultaneous endocardial catheter radiofrequency ablation completed pulmonary vein isolation, performed a mitral annular and cavotricuspid isthmus line of block, and debulked the coronary sinus. Twelve-month results for the Convergent procedure were compared with 12-month results for concomitant and pericardioscopic (stand-alone transdiaphragmatic/thoracoscopic) atrial fibrillation procedures using unipolar radiofrequency ablation. Sixty-five patients underwent the Convergent procedure (mean age, 62 y; mean body surface area, 2.17 m²; mean atrial fibrillation duration, 4.8 y; mean left atrial size, 5.2 cm). Ninety-two percent were in persistent or long-standing persistent atrial fibrillation. At 12 months, evaluation with 24-hour Holter monitors found 82% of patients in sinus rhythm, while only 47% of pericardioscopic and 77% of concomitant patients treated with unipolar radiofrequency ablation were in sinus rhythm. Simultaneous epicardial and endocardial ablation improves outcomes for patients with persistent or longstanding persistent atrial fibrillation. This successful collaboration between cardiac surgeon and electrophysiologist is an important treatment option for patients with large left atriums and chronic atrial fibrillation.

Full-text

Available from: Andrej Pernat, Oct 10, 2014
ORIGINAL ARTICLE
Simultaneous Catheter and Epicardial Ablations Enable a
Comprehensive Atrial Fibrillation Procedure
Andy C. Kiser, MD,* Mark D. Landers, MD,† Ker Boyce, MD,† Matjaz˘S
˘
inkovec, MD,‡
Andrej Pernat, MD,‡ and Borut Geršak, MD, PhD§
Objective: Transmural and contiguous ablations and a comprehen-
sive lesion pattern are difficult to create from the surface of a beating
heart but are critical to the successful treatment of persistent,
isolated atrial fibrillation. A codisciplinary simultaneous epicardial
(surgical) and endocardial (catheter) procedure (Convergent proce-
dure) addresses these issues.
Methods: Patients with symptomatic atrial fibrillation who failed
medical treatment were evaluated. Using only pericardioscopy, the
surgeon performed near-complete epicardial isolation of the pulmo-
nary veins and a “box” lesion on the posterior left atrium using
unipolar radiofrequency ablation. Simultaneous endocardial catheter
radiofrequency ablation completed pulmonary vein isolation, per-
formed a mitral annular and cavotricuspid isthmus line of block, and
debulked the coronary sinus. Twelve-month results for the Convergent
procedure were compared with 12-month results for concomitant and
pericardioscopic (stand-alone transdiaphragmatic/thoracoscopic) atrial fi-
brillation procedures using unipolar radiofrequency ablation.
Results: Sixty-five patients underwent the Convergent procedure
(mean age, 62 y; mean body surface area, 2.17 m
2
; mean atrial
fibrillation duration, 4.8 y; mean left atrial size, 5.2 cm). Ninety-two
percent were in persistent or long-standing persistent atrial fibrilla-
tion. At 12 months, evaluation with 24-hour Holter monitors found
82% of patients in sinus rhythm, while only 47% of pericardioscopic
and 77% of concomitant patients treated with unipolar radiofre-
quency ablation were in sinus rhythm.
Conclusions: Simultaneous epicardial and endocardial ablation im-
proves outcomes for patients with persistent or longstanding persis-
tent atrial fibrillation. This successful collaboration between cardiac
surgeon and electrophysiologist is an important treatment option for
patients with large left atriums and chronic atrial fibrillation.
Key Words: Atrial fibrillation, Ablative therapy, Arrhythmia sur-
gery, Hybrid procedures.
(Innovations 2011;6:243–247)
T
he surgical treatment of atrial fibrillation (AF) has varied
greatly since Cox first reported the Maze procedure in 1987.
1
Minimally invasive surgical approaches have eliminated sternot-
omy and cardiopulmonary bypass but have failed to fully repli-
cate the complete Maze pattern.
2– 4
Existing surgical energy sources
and ablation devices are limited to epicardial treatments and cannot
create the important lesions at the mitral valve annulus or at the
cavotricuspid isthmus. The Ex-Maze procedure is an example of a
totally endoscopic surgical AF treatment limited to the epicardial
surface of the beating heart. Without the endocardial lesions, a
minimally invasive, beating heart AF procedure is incomplete.
Electrophysiologists can successfully create lines of
ablation at the mitral valve annulus and at the cavotricuspid
isthmus using endocardial catheters. Through collaboration, a
simultaneous endocardial and epicardial ablation procedure, the
Convergent procedure, satisfies the deficiencies experienced
with epicardial AF procedures alone. Further, electrophysiolo-
gists provide the additional expertise of electrical interrogation
of the left and right atria. Using mapping electrodes, they
effectively confirm lesion contiguity and ensure pulmonary vein
isolation. The result is a comprehensive and biatrial ablation
procedure, to include important endocardial lesions, without a
chest incision or cardiopulmonary bypass. We compare 12-
month outcomes of the Convergent procedure with concomitant
and stand-alone epicardial ablation procedures to treat AF.
METHODS
Patients with symptomatic and persistent AF were
evaluated and selected to undergo the Convergent procedure
5
between January 2009 and May 2010. All patients had pre-
viously failed medical management as defined by failure to
maintain sinus rhythm after cardioversion and treatment with
class I/IIIa antiarrhythmic drugs (AADs). The cardiac sur-
geon and the electrophysiologist examined the patients before
Accepted for publication July 6, 2011.
From the *Division of Cardiothoracic Surgery, University of North Carolina
at Chapel Hill, Chapel Hill, NC USA; †FirstHealth Arrhythmia Center,
Pinehurst, NC USA; ‡Department of Cardiology, University Medical
Center Ljubljana, Ljubljana, Slovenia; and §Department of Cardiovas-
cular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia.
Presented at the Annual Scientific Meeting of the International Society for Mini-
mally Invasive Cardiothoracic Surgery, June 16 –19, 2010, Berlin, Germany.
Disclosures: Andy C. Kiser, MD, is a stockholder in nContact, Morris-
ville, NC USA. Borut Geršak, MD, PhD, is a paid consultant of nContact,
Morrisville, NC USA. Mark D. Landers, MD, Ker Boyce, MD, Matjaz˘
S
˘
inkovec, MD, and Andrej Pernat, MD, declare no conflict of interest.
nContact, Morrisville, NC USA provided no support for this study.
Address correspondence and reprint requests to Andy C. Kiser, MD, Divi-
sion of Cardiothoracic Surgery, University of North Carolina at Chapel
Hill, 3040 Burnett Womack Bldg., CB 7065, Chapel Hill, NC 27599-
7065 USA. E-mail: andy_kiser@med.unc.edu.
Copyright © 2011 by the International Society for Minimally Invasive
Cardiothoracic Surgery
ISSN: 1556-9845/11/0604-0243
Innovations Volume 6, Number 4, July/August 2011 243
Page 1
the procedure and, when appropriate, implanted long-term
monitoring devices (Reveal; Medtronic, Minneapolis, MN
USA).
The procedures were performed under general anesthe-
sia in a hybrid electrophysiology/operating room suite with
integrated fluoroscopy, endoscopy, general anesthesia, and
CARTO (Biosense; Webster, Inc., Diamond Bar, CA USA)
mapping and imaging technologies. A 2-cm subxyphoid in-
cision with a 10-mm port and two 5-mm laparoscopic ports
were used to open the central fibrous region of the diaphragm
and the pericardium under endoscopic visualization (Karl
Storz Endoscopy, Tuttlingen, Germany). A cannula inserted
into the pericardium provided endoscopic visualization and
access to the left atrium (Fig. 1). The posterior left atrial
epicardial surface was electrically mapped before ablation.
Using an irrigated, unipolar radiofrequency ablation device
(Visitrax; nContact Surgical, Morrisville, NC USA), epicar-
dial lesions were created on the left and right pulmonary
veins, the posterior left atrium, the lateral right atrium, and
the ligament of Marshall within the transverse sinus (solid
lines, Fig. 2). At completion, the posterior left atrial epicar-
dial surface was mapped again to confirm electrical silence.
On completion of the epicardial, surgical portion of the
procedure, the electrophysiologist began the endocardial por-
tion of the Convergent procedure (dotted lines, Fig. 2).
Because of the undissected pericardial reflections, the epicar-
dial ablations were usually not contiguous at the superior left
and right and at the right inferior pulmonary veins. Each
pulmonary vein was mapped with a multipolar circular cath-
eter, and areas of activity identified in the pulmonary vein
antrums were ablated endocardially until all of the pulmonary
veins demonstrated entrance and exit block. Similarly, the
posterior left atrium between the pulmonary veins was
mapped and electrical silence confirmed. A series of endo-
cardial ablations were applied in an effort to isolate the
coronary sinus. A line of ablation was created at the cavotri-
cuspid isthmus and at the mitral valve annulus with confir-
mation of block. All Convergent patients received the lesion
pattern in Figure 2.
On completion of the endocardial portion of the Con-
vergent procedure, rapid atrial pacing while on isoproterenol
was performed to elicit and treat residual sources of atrial
arrhythmias. Anticoagulation was then corrected and the
venous sheaths were removed when the anticoagulation ther-
apy was less than 200. A drain was placed in the pericardial
space and the midline fascia closed. The patients were gen-
erally extubated in the operating room and were usually ready
for discharge in 36 to 72 hours. Using an Enoxaparin (Sanofi-
Aventis, Bridgewater, NJ USA) bridge, Warfarin (Bristol-
Myers Squibb, New York, NY USA) therapy was initiated
the night of the procedure and continued at least 3 months.
Antiarrhythmic medications were initiated but were discon-
tinued by 3 months when clinically appropriate. The patients
FIGURE 1. Transdiaphragmatic periocardioscopic
approach for surgical epicardial ablation.
FIGURE 2. The Convergent procedure endocardial and epi-
cardial lesion pattern as viewed from the posterior left
atrium.
Kiser et al Innovations Volume 6, Number 4, July/August 2011
Copyright © 2011 by the International Society for Minimally Invasive Cardiothoracic Surgery244
Page 2
were evaluated at 12 months with routine electrocardiogram
evaluation and with a 24-hour Holter or continuous Reveal
(Medtronic) monitor interrogation.
The outcomes of patients undergoing the Convergent
procedure were compared with patients undergoing a similar
open-chest, concomitant epicardial ablation procedure with
the same unipolar Visitrax device, the Ex-Maze procedure,
6
and a similar closed chest thoracoscopic/pericardioscopic
Ex-Maze procedure (Table 1).
7
RESULTS
A total of 65 patients (5 paroxysmal; 12 persistent; 48
long-standing persistent) underwent the Convergent proce-
dure between January 2009 and May 2010. Sixty patients
were alive and available for evaluation but only 42 patients
had 12-month data available. These patients were compared
with 117 total patients (11 paroxysmal, 21 persistent, 71
long-standing persistent, and 12 unknown) who were treated
with an open chest concomitant Ex-Maze procedure between
August 2006 and February 2010 and 61 total patients (13
persistent and 48 long-standing persistent) who were treated
with a thoracoscopic/pericardioscopic Ex-Maze procedure
between June 2007 and December 2008. With the exception
of the open chest patients, who tended to be older, left atrial
size and left ventricular ejection fraction were similar. Sinus
rhythm with and without antiarrhythmic medications at 12
months were compared as documented by electrocardiogram
and by 24-hour Holter monitors (Table 2). Chi-square anal-
ysis of the comparison reached statistical significance (P
0.05) between all groups except for the comparison between
the open and Convergent groups for sinus rhythm (P
0.076) and sinus rhythm without AADs (P 0.051). Nine-
teen patients in the Convergent group had continuous moni-
toring with Reveal. Sinus rhythm was defined as the absence
of AF, atrial flutter, or atrial tachyarrhythmias lasting more
than 30 seconds.
8
Reveal outcomes were reported as the
rhythm during 24 hours of device interrogation at the 12-
month interval. The average surgical ablation procedure
TABLE 1. Comparative Demographics for the Convergent Procedure
Open Chest Concomitant
Ex-Maze
Pericardioscopic/Thoracoscopic
Ex-Maze Convergent Procedure
(n 117) (n 61) (n 65)
Age (y) 70 60 62
Left atrial size (cm) 5.5 5.2 5.2
Left ventricular ejection fraction (%) 50.4 50.5 53.4
TABLE 2. Comparative Outcomes of the Convergent Procedure
Open Chest
Concomitant
Ex-Maze
Pericardioscopic/
Thoracoscopic
Ex-Maze
Convergent
Procedure
(n 117) (n 61) (n 65)
Holter or ECG
at 12 mo
Holter at
12 mo
Holter or ECG
at 12 mo
Holter at
12 mo
Holter or ECG
at 12 mo
Holter at
12 mo
Persistent or long-standing persistent AF 89% 100% 92%
Sinus rhythm 80% (53/66) 77% (37/48) 57% (30/53) 47% (22/47) 88%* (37/42) 82%* (32/39)
Sinus rhythm and freedom from antiarrhythmic
medications
71% (47/66) 67% (32/48) 55% (29/53) 47% (22/47) 83%* (35/42) 77%* (30/39)
*Reveal 19 (sinus rhythm 97%).
ECG, electrocardiogram; AF, atrial fibrillation.
Innovations Volume 6, Number 4, July/August 2011 Simultaneous Catheter and Epicardial Ablations
Copyright © 2011 by the International Society for Minimally Invasive Cardiothoracic Surgery 245
Page 3
times for the open Ex-Maze, the thoracoscopic/pericardio-
scopic Ex-Maze, and the Convergent procedures were 58, 240,
and 170 minutes, respectively. The average endocardial proce-
dure time for the Convergent procedure was 172 minutes.
Of the patients undergoing the Convergent procedure,
one had a simultaneous minimally invasive mitral valve
repair via a 7-cm right submammary incision and remains in
sinus rhythm at 18 months. Two patients developed a peri-
cardial effusion 2 weeks postprocedure requiring percutane-
ous drainage. Both recovered fully and remain in sinus
rhythm at 12 months. No hemodynamically significant peri-
cardial effusions have occurred because drainage of the
pericardium postprocedure became standard. One patient,
discharged on Dofetilide (Pfizer, New York, NY USA),
suffered sudden cardiac death 7 days postprocedure undoubt-
edly related to Torsades de pointes as no other cause of death
was discovered at autopsy. Two patients developed atrial-
esophageal fistulas, dying at 10 and 14 days postprocedure.
One patient relocated and has been lost to follow-up. One
patient underwent aortic root replacement for an expanding
aneurysm. He had also developed recurrent AF mapped to the
right atrium, which was successfully treated with intraoper-
ative ablation to this area.
DISCUSSION
The shortfall of minimally invasive surgical AF proce-
dures has been the inability to consistently create lesions that
extend from the epicardium to the endocardium, specifically to
the mitral valve or tricuspid valve annulus, and a relative
inability to reliably interrogate procedural completeness. There
is no epicardial energy source or device available that creates
lesions at the mitral valve annulus or the cavotricuspid isthmus
on a beating heart. Patients undergoing the concomitant Ex-
Maze procedure and the thoracoscopic/pericardioscopic Ex-
Maze procedure did not have endocardial ablation lines. Addi-
tionally, during these two procedures, we tested only for exit
block at the right superior pulmonary vein. To demonstrate
potential advantages of adding the endocardial ablations, we
compared the epicardial procedures to the Convergent proce-
dure. During the Convergent procedure, the electrophysiologist
adds endocardial lesions to connect the epicardial lesions and
ablate areas inaccessible from the epicardium. Additionally,
upon completion, the patient undergoes electrophysiologic map-
ping/interrogation and rapid atrial pacing while on isoproterenol
to elicit residual sources of atrial arrhythmias. Any dysarrhyth-
mias uncovered during interrogation are treated. By adding the
important endocardial lines of ablation and interrogating the
completed pattern, we are confident that all has been done to
fully address any potential arrhythmias.
These results indicate that, compared with surgical
ablation procedures alone, collaboration with electrophysi-
ologists improves outcomes. The patients who underwent
concomitant Ex-Maze procedures may have had better out-
comes than the thoracoscopic/pericardioscopic Ex-Maze pa-
tients because their structural heart disease was treated. How-
ever, 77% of the Convergent patients were in sinus rhythm
without AAD at 12 months, while only 47% of pericardio-
scopic patients were in sinus rhythm without AAD at 12
months. These results were of statistical significance by
2
analysis. The outcome improvement may reflect the addi-
tional endocardial lesions or the electrophysiologic interro-
gation at procedure completion.
Unlike the standard “cut and sew” maze, the left atrial
appendage is not addressed during the Convergent procedure.
The risk of bleeding complications during endoscopic removal
of the appendage are frequent and seem prohibitive with current
technology, even with thoracoscopy.
9
Until safe and effective
minimally invasive appendage management is available, close
rhythm monitoring with appropriate anticoagulation is an effec-
tive alternative. Postconvergent monitoring with long-term or
implantable event monitors provides convincing evidence of
procedural success and may support the discontinuation of
anticoagulation within CHADS2 guidelines.
10
The group of patients undergoing Convergent proce-
dures experienced complications not seen in the stand-alone
and concomitant procedure groups. Symptomatic pericardial
effusions may have been masked because the pericardium
was open into the pleural space or drained with mediastinal
tubes previously. After a pericardial drainage tube was added
for 48 hours, the Convergent patients did not experience
further problems with pericardial effusions. Atrial-esopha-
geal fistulas were also not seen previously in the other groups.
Although the exact source of thermal injury to the esophagus
was not identified, both the radiofrequency ablation catheter
and surgical device are possible culprits and have been
previously reported.
11,12
The energy of unipolar surgical ab-
lation devices, when compared with bipolar devices, may be
less focused with more risk of collateral tissue injury. How-
ever, during pericardioscopy the energy is delivered epicar-
dially toward the heart and away from the esophagus. Fur-
thermore, the ablation device is positioned under direct
vision, theoretically reducing collateral injury. Avoiding in-
tercostal incisions and not entering the thorax reduce pain and
pleural space complications (effusions/bleeding). But these
benefits cannot overshadow the complications of esophageal
injury. Careful attention to the direction of energy application
while positioning the device, monitoring esophageal temper-
ature changes with a temperature probe, identifying and
avoiding the esophagus with fluoroscopy, and irrigating the
pericardium with cool saline are measures we have instituted
to mitigate esophageal injury.
This is a small group of patients demonstrating the
feasibility of the procedure. The complications of atrial-
esophageal fistula and associated mortality deserve a word of
caution. The authors recommend didactic and practical train-
ing by surgeons experienced in pericardioscopy and unipolar
epicardial ablation before adopting this technique. The safety
and efficacy of the Convergent procedure will be better
defined with more experience in a larger patient population.
A codisciplinary collaboration between cardiac sur-
geons and electrophysiologists is necessary for the successful
minimally invasive treatment of persistent AF. The integra-
tion of a surgeon’s anatomic approach to AF with the elec-
trophysiologist’s physiologic approach is the foundation for
the Convergent procedure. Areas of viable tissue within or
between epicardial lesions are quickly identified and elimi-
Kiser et al Innovations Volume 6, Number 4, July/August 2011
Copyright © 2011 by the International Society for Minimally Invasive Cardiothoracic Surgery246
Page 4
nated with endocardial recording electrodes and ablation
catheters. Furthermore, important lesions at the mitral valve
annulus, within the coronary sinus, and at the cavotricuspid
isthmus can be created endocardially to complete the com-
prehensive Convergent procedure pattern. The integration of
surgical and electrophysiologic expertise in a single proce-
dure eliminates failures encountered individually and empha-
sizes the positive aspect of each approach.
ACKNOWLEDGMENTS
The authors thank Thomas M. Egan, MD, for statistical
assistance and Margaret Alford Cloud for editorial assistance.
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Innovations Volume 6, Number 4, July/August 2011 Simultaneous Catheter and Epicardial Ablations
Copyright © 2011 by the International Society for Minimally Invasive Cardiothoracic Surgery 247
Page 5
  • [Show abstract] [Hide abstract] ABSTRACT: BACKGROUND: Catheter ablation is an effective treatment for medically refractory, disabling atrial fibrillation (AF). Ablation success may be limited in patients with persistent or long-standing persistent AF. A pericardioscopic, hybrid epicardial-endocardial technique for AF ablation may be a preferred approach for such patients. Limited data are available by using such an approach. OBJECTIVE: XXX METHODS: A cohort of 101 patients underwent AF ablation using a transdiaphragmatic pericardioscopic, hybrid epicardial-endocardial technique. Patients were followed with 24-hour Holter monitors at 3-, 6-, and 12-month intervals. Symptom severity was assessed at baseline and follow-up by using the Canadian Cardiovascular Society Severity of Atrial Fibrillation scale. RESULTS: Mean AF duration was 5.9 years; 47% were persistent and 37% were long-standing persistent. Mean left atrial size was 5.1 cm (range 3.3-7 cm). Overall, 12-month arrhythmia-free survival was 66.3% after a single ablation procedure and 70.5% including repeat ablation. Repeat ablation was required in 6% of the patients and antiarrhythmic drug therapy in 37% of the patients. Quality of life improved significantly and was durable over 12-month follow-up. There were 2 deaths, which occurred in the early postoperative period: one due to atrioesophageal fistula and the second due to sudden cardiac death without apparent cause by autopsy. CONCLUSIONS: We report the largest series to date of a hybrid epicardial-endocardial, stand-alone ablation procedure using a pericardioscopic technique for the treatment of AF. While respecting the identified complications, our results demonstrate a high potential for successful treatment in a challenging patient population with AF.
    Full-text · Article · Sep 2012 · Heart rhythm: the official journal of the Heart Rhythm Society
    0Comments 23Citations
  • [Show abstract] [Hide abstract] ABSTRACT: Catheter ablation of atrial fibrillation (AF) has been shown to be effective for paroxysmal AF. However, for patients with persistent or longstanding persistent AF, the success rates for catheter ablation is low. The Cox-Maze procedure is the most effective non-pharmacological treatment of AF. However, due to the need for open-heart surgery and the morbidity associated with the surgical Cox-Maze procedure, minimally invasive and epicardial-endocardial (hybrid) ablation procedures have been developed. This article will review the main surgical and hybrid approaches used for the treatment of persistent and long-standing persistent AF. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Jan 2015 · Current Problems in Cardiology
    0Comments 1Citation
  • [Show abstract] [Hide abstract] ABSTRACT: IntroductionLeft atrial appendage (LAA) ligation results in LAA electrical isolation and a decrease in atrial fibrillation (AF) burden. This study assessed the feasibility of combined percutaneous LAA ligation and pulmonary vein isolation (PVI) in patients with persistent AF.Methods and Results22 patients with persistent AF underwent LAA ligation with the LARIAT device followed by PVI. PVI was confirmed with the demonstration of both entrance and exit block. Patients (n = 10) in sinus rhythm pre- and post-LAA ligation underwent P-wave analysis. Monitoring for AF was performed at 1, 3 and 6 months post ablation.LAA ligation was successful in 21 of 22 (95%) patients. The procedure was aborted in one patient due to pericardial adhesions. PVI was performed in 20 of 21 patients. One patient converted to atrial flutter with a controlled ventricular response after LAA ligation and refused subsequent PVI. Demonstration of entrance and exit block was achieved in 19 of 20 patients. At 3 months, 13 of 19 (68.4%) patients were in sinus rhythm. 4 patients underwent a second PVI. At 6 months, 15 of 20 (75%) patients were in sinus rhythm. There was a significant decrease in P-wave duration and P-wave dispersion after LAA ligation. Complications with LAA ligation included pericarditis, a delayed pleural effusion and a late pericardial effusion.Conclusions Staged LAA ligation and PVI is feasible and decreases P-wave dispersion. Randomized studies are needed to assess the efficacy of LAA ligation as adjunctive therapy to PVI for maintaining sinus rhythm in patients with persistent AF.This article is protected by copyright. All rights reserved.
    No preview · Article · Mar 2015 · Journal of Cardiovascular Electrophysiology
    0Comments 6Citations

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