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Hybrid Ablation Procedures of Atrial Fibrillation—How to Optimize Patient Selection and Improve the Procedural Approach

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David De Lurgio at Emory University
David De Lurgio
Marcie R Meador at Baylor College of Medicine
Marcie R Meador
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Purpose of Review Traditional surgical ablation and endocardial catheter ablation have historically been the primary ablation approaches for treating atrial fibrillation (AF) concomitantly with another surgical procedure or as a standalone procedure, respectively. In the last several years, hybrid epicardial-endocardial ablation utilizing a subxiphoid approach for epicardial left atrial ablation combined with endocardial catheter ablation (converge procedure) has been an emerging hybrid approach to standalone AF catheter ablation. The procedure was developed as a treatment option for patients with advanced AF in which traditional catheter ablation had limited efficacy and relief. The technique combines the benefits of both endocardial and epicardial ablation in a minimally invasive manner to provide a comprehensive lesion set characterized by durable transmural lesions. The Convergent technique involves a minimally invasive surgical addition to standard endocardial ablation. Identifying appropriate patients for this approach and optimizing procedural details will assist clinicians in decision-making. In this review we discuss optimization of patient selection for the convergent procedure and tools and techniques to maximize workflow and clinical outcomes. Recent Findings The dual epicardial-endocardial nature of hybrid may be in part why the hybrid convergent procedure has been successful in treating even longstanding persistent AF (LSPAF), which was previously thought to be permanent with high recurrence rates that have not improved despite advances in catheter ablation technology (Winkle et al., 2023). As shown in randomized and propensity score-matched cohorts, effectiveness rates for hybrid convergent ablation are improved compared to endocardial ablation for advanced AF. Adverse events can be minimized through best practice risk mitigations resulting in an acceptable safety profile (Makati et al., in Heart Rhythm 18(2):303-312, 2021; Eranki et al., in J Cardiothorac Surg 17(1), 2022). Summary Treating advanced AF with endocardial ablation alone has been challenging, and outcomes have been suboptimal. The convergent procedure has proven to be more effective but does require the addition of minimally invasive surgery. As more centers implement hybrid AF ablation, attention must turn to improving the procedural approach and optimizing patient selection based on available clinical data.
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1 3
Current Cardiovascular Risk Reports (2023) 17:133–141
https://doi.org/10.1007/s12170-023-00722-5
Hybrid Ablation Procedures ofAtrial Fibrillation—How toOptimize
Patient Selection andImprove theProcedural Approach
DavidB.DeLurgio1,2 · MarcieR.Meador3
Accepted: 8 May 2023 / Published online: 19 June 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023
Abstract
Purpose of Review Traditional surgical ablation and endocardial catheter ablation have historically been the primary ablation
approaches for treating atrial fibrillation (AF) concomitantly with another surgical procedure or as a standalone procedure,
respectively. In the last several years, hybrid epicardial-endocardial ablation utilizing a subxiphoid approach for epicardial
left atrial ablation combined with endocardial catheter ablation (converge procedure) has been an emerging hybrid approach
to standalone AF catheter ablation. The procedure was developed as a treatment option for patients with advanced AF in
which traditional catheter ablation had limited efficacy and relief. The technique combines the benefits of both endocardial
and epicardial ablation in a minimally invasive manner to provide a comprehensive lesion set characterized by durable trans-
mural lesions. The Convergent technique involves a minimally invasive surgical addition to standard endocardial ablation.
Identifying appropriate patients for this approach and optimizing procedural details will assist clinicians in decision-making.
In this review we discuss optimization of patient selection for the convergent procedure and tools and techniques to maximize
workflow and clinical outcomes.
Recent Findings The dual epicardial-endocardial nature of hybrid may be in part why the hybrid convergent procedure has
been successful in treating even longstanding persistent AF (LSPAF), which was previously thought to be permanent with
high recurrence rates that have not improved despite advances in catheter ablation technology (Winkle etal., 2023). As
shown in randomized and propensity score-matched cohorts, effectiveness rates for hybrid convergent ablation are improved
compared to endocardial ablation for advanced AF. Adverse events can be minimized through best practice risk mitigations
resulting in an acceptable safety profile (Makati etal., in Heart Rhythm 18(2):303-312, 2021; Eranki etal., in J Cardiothorac
Surg 17(1), 2022).
Summary Treating advanced AF with endocardial ablation alone has been challenging, and outcomes have been suboptimal.
The convergent procedure has proven to be more effective but does require the addition of minimally invasive surgery. As
more centers implement hybrid AF ablation, attention must turn to improving the procedural approach and optimizing patient
selection based on available clinical data.
Keywords Longstanding persistent atrial fibrillation· Hybrid ablation· Convergent procedure
Introduction
Traditional surgical ablation and endocardial catheter abla-
tion have historically been the primary ablation approaches
for treating atrial fibrillation (AF) concomitantly with
another surgical procedure or as a standalone procedure,
respectively. In the last several years, hybrid epicardial-
endocardial ablation utilizing a subxiphoid approach for
epicardial left atrial ablation combined with endocardial
catheter ablation (converge procedure) has been an emerg-
ing hybrid approach to standalone AF catheter ablation. The
procedure was developed as a treatment option for patients
* David B. De Lurgio
ddelurg@emory.edu
1 School ofMedicine, Emory University, Atlanta, GA, USA
2 Emory St. Joseph’s Hospital, Atlanta, GA, USA
3 AtriCure, Inc, 7555 Innovation Way, Mason, OH45040,
USA
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Individually, neither approach can achieve complete transmurality due to thickness of the tissue, however taken together, the goal of the combined approach is to create overlapping and contiguous lesions to create a transmural barrier to abnormal conduction. The role of the collaborative patient-centered, multi-disciplinary heart team is vital in determining the appropriate patients for consideration of hybrid therapies as well as ensuring an optimal risk-benefit assessment and maximizing treatment outcomes for historically difficult to treat patient populations [113,114]. ...
Hybrid Endo-Epicardial Therapies for Advanced Atrial Fibrillation
Article
Full-text available
  • Jan 2024
Atrial fibrillation (AF) is a growing health problem that increases morbidity and mortality, and in most patients progresses to more advanced diseases over time. Recent research has examined the underlying mechanisms, risk factors, and progression of AF, leading to updated AF disease classification schemes. Although endocardial catheter ablation is effective for early-stage paroxysmal AF, it consistently achieves suboptimal outcomes in patients with advanced AF. Identification of the factors that lead to the increased risk of treatment failure in advanced AF has spurred the development and adoption of hybrid ablation therapies and collaborative heart care teams that result in higher long-term arrhythmia-free survival. Patients with non-paroxysmal AF, atrial remodeling, comorbidities, or AF otherwise deemed difficult to treat may find hybrid treatment to be the most effective option. Future research of hybrid therapies in advanced AF patient populations, including those with dual diagnoses, may provide further evidence establishing the safety and efficacy of hybrid endo-epicardial ablation as a first line treatment.
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Very Long-Term Outcomes of Atrial Fibrillation Ablation
Article
Full-text available
  • Feb 2023
  • HEART RHYTHM
Background: Little is known about the very long-term durability of AF ablation. Objective: Evaluate very long-term AF ablation outcomes. Methods: We followed 5200 patients undergoing 7145 ablations. We evaluated outcomes after single and multiple ablations for paroxysmal(PAF)(33.6%), persistent(PeAF)(56.4%) and long-standing(LsAF)(9.9%) AF. We compared 3 ablation eras by initial ablation catheter: early(101 pts) using solid big tip(SBT) catheters(10/2003-12/2005), intermediate(2143 pts) using open irrigated tip(OIT) catheters(12/2005-8/2016) and contemporary(2956 pts) using contact force(CF) catheters(3/2014-12/2021). Results: AF freedom at 5, 10 and 15 years was: initial ablation: PAF(67.8%,56.3%,47.6%), PeAF(46.6%,35.6%,26.5%), LsAF(30.4%,18.0%,3.4%), final ablation: PAF(80.3%,72.6%,62.5%), PeAF(60.1%,50.2%,42.5%), LsAF(43.4%,32.0%,20.6%). For PAF and PeAF, CF ablations were better than OIT(P<0.0001) and both better than SBT(P<0.001). LsAF had no outcome improvement over the eras. Eight-year success after final ablation for the CF, OIT and SBT catheters was: PAF(79.1%,71.8%,60.0%), PeAF(55.9%,50.7%,38.0%), LsAF(42.7%,36.2%,31.8%). Highest AF recurrence was in the first 2 years with a year 2-15-year recurrence of 2%/year. Success predictors after initial and final ablations were younger age, smaller left atrium(LA), shorter AF duration, male sex, less persistent AF, lower CHA2DS2VASc score, fewer drugs failed and more recent catheter era. Conclusions: After year 2 there is 2%/year recurrence rate for all AF types. Ablation success is best in the CF era, intermediate in the OIT era and worst in the SBT era. Over the ablation eras, outcomes improved for PAF and PeAF but not for LsAF. We should follow patients indefinitely after ablation. We need an understanding of how to better ablate more persistent AF.
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Hybrid Epicardial-Endocardial Ablation for Long-Standing Persistent Atrial Fibrillation: A Subanalysis of the CONVERGE Trial
Article
Full-text available
  • Dec 2022
Background Favorable clinical outcomes are difficult to achieve in longstanding persistent atrial fibrillation (LSPAF) with Catheter Ablation (CA). CONVERGE evaluated the effectiveness of Hybrid Convergent (HC) ablation versus endocardial CA. Objective To evaluate safety and effectiveness of HC versus CA in the LSPAF subgroup from CONVERGE. Methods CONVERGE was a prospective, multi-center, randomized trial that enrolled 153 patients at 27 sites. A post-hoc analysis was performed on LSPAF patients. Primary effectiveness was freedom from atrial arrhythmias off new or increased dose of previously failed/intolerant anti-arrhythmic drugs (AADs) through 12-months. Primary safety endpoint was major adverse event (MAE) incidence through 30 days with HC. Key secondary effectiveness measures included (1) % patients achieving ≥90% AF burden reduction versus baseline and (2) AF freedom. Results Sixty-five patients (42.5% of total enrollment) had LSPAF; 38 in HC and 27 in CA. Primary effectiveness was 65.8% (95% CI: 50.7-80.9%) with HC versus 37.0% (95% CI: 5.1-52.4%) with CA (P=0.022). Through 18-months, these rates were 60.5% (95% CI: 50.0-76.1%) with HC versus 25.9% (95% CI: 9.4-42.5%) with CA (P=0.006). Secondary effectiveness rates were higher than CA with HC at 12- and 18-months. Freedom from atrial arrhythmias off AADs was 52.6% (95% CI: 36.8-68.5%) and 47.4% (95% CI: 31.5-63.2%) with HC at 12- and -18-months versus 25.9% (95% CI: 9.4-42.5%) and 22.2% (95% CI: 6.5-37.9%) with CA, respectively (12-months: P=0.031; 18-months: P=0.038). Three (7.9%) MAEs occurred within 30 days of HC. Conclusion Post-hoc analysis demonstrated effectiveness and acceptable safety of HC compared with CA in LSPAF.
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Convergent Ablation for Persistent Atrial Fibrillation: Outcomes from a Single-Center Real-world Experience
Article
Full-text available
  • Nov 2022
  • EUR J CARDIO-THORAC
OBJECTIVES Atrial fibrillation (AF) is common and can cause significant morbidity and detriment to quality of life. Success rates for conventional catheter ablation are suboptimal in persistent AF (PsAF), especially when longstanding. Convergent hybrid ablation combines endoscopic surgical epicardial and endocardial catheter ablation. It offers promise in treating PsAF. We aimed to evaluate outcomes at our centre following convergent ablation. METHODS We conducted an observational study of patients undergoing ablation from 2012 to 2019 at a London cardiac centre. Sixty-seven patients underwent convergent ablation entailing epicardial ablation, mostly via sub-xiphoid access, followed by endocardial left atrial catheter ablation. Baseline and follow-up data were obtained retrospectively from clinical records. Primary outcome was freedom from AF on/off anti-arrhythmic drugs after 12-month follow-up. Secondary outcomes included freedom from AF over the entire follow-up, freedom from anti-arrhythmic drugs, freedom from atrial arrhythmias, symptom status, repeat ablation and complications. RESULTS At baseline, 80.6% had PsAF >1 year (80.6%), 49.3% had body mass index >30 kg/m2 at baseline and 19.4% had left ventricular ejection fraction of 40% or less. The median follow-up was 2.3 (1.4–3.7) years. Freedom from AF recurrence was 81.3% at 1 year and 61.5% over overall follow-up. Eleven patients (16.4%) required redo AF ablation. Prolonged AF duration was associated with increased recurrence at 12 months and duration >5 years with a shorter time to recurrence on Kaplan–Meier analysis, but this and other factors did not significantly impact the AF recurrence during the overall follow-up period. CONCLUSIONS Convergent ablation had good 1-year and overall success rates for treating PsAF. Our results in a diverse, real-world population support the potential of convergent ablation in patients with challenging to treat PsAF.
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Hybrid Ablation of Persistent and Long-Standing Persistent Atrial Fibrillation with Depressed Ejection Fraction: A Single Center Observational Study
Article
Full-text available
  • Sep 2022
Objective: The relationship between atrial fibrillation (AF) and heart failure with depressed ejection fraction (EF) is complex. AF-related tachycardia-mediated cardiomyopathy (TMC) can lead to worsening EF and clinical heart failure. We sought to determine whether a hybrid team ablation approach (HA) can be performed safely and restore normal sinus rhythm in patients with TMC and heart failure and to delineate the effect on heart failure. Methods: We retrospectively analyzed patients with nonparoxysmal (ie, persistent and long-standing persistent) AF-related TMC with depressed left ventricular EF (LVEF ≤40%) and heart failure (New York Heart Association [NYHA] class ≥2) who underwent HA between 2013 and 2018 and had at least 1 year of follow-up. Pre-HA and post-HA echocardiograms were compared for LVEF and left atrial (LA) size. Rhythm success was defined as <30 seconds in AF/atrial flutter/atrial tachycardia without class I or III antiarrhythmic drugs. Results are expressed as mean ± SD and 95% confidence interval (CI) of the mean. Results: Forty patients met the criteria for inclusion in our analysis. The mean patient age was 67 ± 9.4 years. The majority of patients had long-standing persistent AF (26 of 40; 65%), and the remainder had persistent AF (14 of 40; 35%). All patients had NYHA class II or worse heart failure (NYHA class II, 36 of 40 [90%]; NYHA class III, 4 of 40 [10%]). The mean time in AF pre-HA was 5.6 ± 6.7 years. All patients received both HA stages. No deaths or strokes occurred within 30 days. Three new permanent pacemakers (7.5%) were placed. Rhythm success was achieved in >60% of patients during a mean 3.5 ± 1.9 years of follow-up. LVEF improved significantly by 12.0% ± 12.5% (95% CI, 7.85%-16.0%; P < .0001), and mean LA size decreased significantly by 0.40 cm ± 0.85 cm (95% CI, 0.69-0.12 cm; P < .01), with a mean of 3.0 ± 1.5 years between pre-HA and post-HA echocardiography. NYHA class improved significantly after HA (mean pre-HA NYHA class, 2.1 ± 0.3 [95% CI, 2.0-2.2]; mean post-HA NYHA class, 1.5 ± 0.6 [95% CI, 1.3-1.7]; P < .0001). Conclusions: Thoracoscopic HA of AF in selected patients with TMC heart failure is safe and can result in rhythm success with structural heart changes, including improvements in LVEF and LA size.
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Hybrid convergent ablation versus endocardial catheter ablation for atrial fibrillation: a systematic review and meta-analysis of randomised control trials and propensity matched studies
Article
Full-text available
  • Aug 2022
  • J CARDIOTHORAC SURG
Introduction Atrial fibrillation (AF) is the most common arrhythmia. Hybrid convergent ablation (HCA) is an emerging procedure for treating longstanding AF with promising results. HCA consists of a subxiphoid, surgical ablation followed by completion endocardial ablation. This meta-analysis of randomized control trials (RCT’s) and propensity score-matched studies aims to examine the efficacy and safety of HCA compared to endocardial catheter ablation (ECA) alone on patients with AF. Methods This review was written in accordance with preferred reporting items for systematic reviews and meta-analyses recommendations and guidance. The primary outcome for the analysis was freedom from AF (FFAF) at final follow up. Secondary outcomes were mortality and significant complications such as tamponade, sternotomy, esophageal injury, atrio-esophageal fistulae post procedurally. Results Four studies where included, with a total of 233 patients undergoing HCA and 189 patients undergoing ECA only. Pooled analysis demonstrated that HCA cohorts had significantly higher rates of FFAF than ECA cohorts, with an OR of 2.78 (95% CI 1.82–4.24, P < 0.01, I ² = 0). Major post-operative complications were observed in significantly more patients in the HCA group, with an OR of 5.14 (95% CI 1.70–15.54, P < 0.01). There was only one death reported in the HCA cohorts, with no deaths in the ECA cohort. Conclusion HCA is associated with a significantly higher FFAF than ECA, however, it is associated with increased post-procedural complications. There was only one death in the HCA cohort. Large RCT’s comparing the HCA and ECA techniques may further validate these results.
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Hybrid Convergent Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis
Article
Full-text available
  • May 2022
Background Hybrid Convergent ablation for atrial fibrillation (AF) combines minimally invasive surgical (epicardial) and catheter (endocardial) ablation. The procedural goal is to achieve more extensive, enduring ablation of AF substrate around the pulmonary veins, posterior wall, and vestibule of the posterior wall left atrium. Objective To perform a systematic review and meta-analysis on safety and effectiveness of contemporary Hybrid Convergent procedures. Methods PubMed, Embase, and manual searches identified primary research articles on Hybrid Convergent. Inclusion criteria focused on contemporary practices (epicardial ablation device and lesions). Clinical outcomes at 1 year or later follow-up, patient population, procedural details and major adverse events (MAE) were recorded. Results Of 249 records, 6 studies (5 observational, 1 randomized controlled trial) including 551 patients were included. Endocardial energy sources included radiofrequency and cryo-balloon. Hybrid Convergent ablation was mostly performed in patients with drug-refractory persistent and longstanding persistent AF. Mean pre-procedural AF duration ranged between 2 and 5.1 years. Most patients (∼92%) underwent Hybrid Convergent in a single hospitalization. At 1 year follow-up or later, 69% (95% confidence interval (CI) : 61%–78%, n = 523) were free from atrial arrhythmias and 50% (95% CI: 42%–58%, n = 343) were free from atrial arrhythmias off Anti-arrhythmic drugs. Thirty-day MAE rate was 6% (95% CI: 3%–8%, n = 551). Conclusion Hybrid Convergent ablation is an effective ablation strategy for persistent and longstanding persistent AF. Contemporary procedural approaches and published strategies aim to mitigate complications reported in early experience and address delayed inflammatory effusions.
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Amplatzer Amulet Left Atrial Appendage Occluder Versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A Randomized, Controlled Trial
Article
Full-text available
  • Aug 2021
Background: Percutaneous closure of the left atrial appendage (LAA) is an alternative to chronic oral anticoagulation to reduce stroke risk in patients with non-valvular atrial fibrillation (NVAF). The Amplatzer™ Amulet™ LAA Occluder IDE Trial (Amulet IDE Trial) was designed to evaluate the safety and effectiveness of the dual-seal mechanism of the Amulet LAA occluder compared with the Watchman™ device. Methods: Patients with NVAF at increased risk of stroke were randomly assigned (1:1) to undergo percutaneous implantation of a LAA occluder with the Amulet occluder or Watchman device. The primary endpoints included safety (composite of procedure-related complications, all-cause death, or major bleeding at 12 months) and effectiveness (composite of ischemic stroke or systemic embolism at 18 months) and the rate of LAA occlusion at 45 days. Pre-specified secondary endpoints included a composite of all stroke, systemic embolism, or cardiovascular/unexplained death at 18 months, major bleeding at 18 months, and superiority test of the three primary endpoints. Results: A total of 1878 patients were enrolled. The Amulet occluder was noninferior to the Watchman device for the primary safety endpoint (14.5% vs. 14.7%; difference=-0.14, 95% CI, -3.42-3.13; p<0.001 for noninferiority). Major bleeding and all-cause death were similar between groups (10.6% vs 10.0% and 3.9% vs 5.1%, respectively). Procedure-related complications were higher for the Amulet occluder (4.5% vs. 2.5%), largely related to more frequent pericardial effusion and device embolization. The Amulet occluder was noninferior to the Watchman device for the primary effectiveness endpoint (2.8% vs. 2.8%; difference=0.00, 95% CI, -1.55-1.55; p<0.001 for non-inferiority), and the composite of stroke, systemic embolism or cardiovascular/unexplained death (5.6% vs 7.7%, difference=-2.12, 95% CI, -4.45-0.21; p<0.001 for noninferiority). The rate of major bleeding was similar between groups (11.6% vs. 12.3%; difference=-0.71, 95% CI -3.72-2.31; p=0.32 for superiority). LAA occlusion was higher for the Amulet occluder compared with the Watchman device (98.9% vs. 96.8%; difference=2.03, 95% confidence interval [CI], 0.41-3.66; p<0.001 for noninferiority; p=0.003 for superiority). Conclusions: The Amulet occluder was non-inferior for safety and effectiveness of stroke prevention for NVAF compared with the Watchman device, and superior for LAA occlusion. Procedure-related complications were higher with the Amulet device and decreased with operator experience. Clinical Trial Registration: URL https://clinicaltrials.gov Unique Identifier NCT02879448
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Abstract 13439: Long-Term Outcomes From Continuous Rhythm Monitoring After Hybrid Convergent Procedure in Longstanding Persistent Atrial Fibrillation Patients
Article
  • Nov 2021
Introduction: Endocardial catheter ablation has suboptimal effectiveness and durability in patients with longstanding persistent atrial fibrillation (LSPAF). Hybrid convergent ablation combines epicardial and endocardial ablation to create a transmural lesion set that isolates the left atrial posterior wall and pulmonary veins. The study objective was to evaluate long-term outcomes assessed by continuous rhythm monitoring in LSPAF patients who received hybrid convergent ablation. Methods: This was a single-center IRB-approved, observational study. Eligible patients were identified by retrospective chart review and included patients who received hybrid convergent procedures between September 2011 and November 2017. Patients were consented for prospective long-term follow-up visits and continuous cardiac monitoring (7-day ePatch). Baseline characteristics, procedural outcomes, and follow-up data were entered into the TRAC-AF registry. This analysis focused on the patient subgroup with pre-operative LSPAF (AF duration >1 year). Results: Of 77 consented patients, 60 had pre-operative LSPAF. Mean age was 66.1 ± 7.9 years, 70% were male, and duration of AF was 6.8 ± 4.8 years. Mean CHA2DS2-VASc score was 2.6 ± 1.4; mean BMI was 32.1 ± 5.9, and 55% (33/60) of patients had previous catheter ablation. Thirty-day major adverse event rate was 5% (3/60) and included 2 inflammatory pericardial effusions and one major bleeding. On continuous monitoring, 71% (41/58) of patients had 0% AF burden at mean follow-up of 61.7 ± 18.9 months. Eight patients (13%) had repeat catheter ablation at mean 21.6 ± 16.3 months since index procedure. Comparison of baseline and follow-up left ventricular ejection fraction (LVEF) from echocardiography revealed a trend of 12.4 ± 13.0 units improvement at mean follow-up of 18.2 ± 23.7 months since baseline in 5 patients with severely reduced (<40%) baseline ejection fraction (p=0.063). Conclusions: Long-term follow-up with continuous monitoring revealed a majority of patients with pre-operative LSPAF had 0% AF burden after a mean 61.7 months since the hybrid convergent procedure. These results are aligned with published studies and the CONVERGE trial on the effectiveness of hybrid convergent ablation in LSPAF.
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Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction: A Scientific Statement From the American Heart Association
Article
  • Jun 2021
Atrial fibrillation and heart failure with reduced ejection fraction are increasing in prevalence worldwide. Atrial fibrillation can precipitate and can be a consequence of heart failure with reduced ejection fraction and cardiomyopathy. Atrial fibrillation and heart failure, when present together, are associated with worse outcomes. Together, these 2 conditions increase the risk of stroke, requiring oral anticoagulation in many or left atrial appendage closure in some. Medical management for rate and rhythm control of atrial fibrillation in heart failure remain hampered by variable success, intolerance, and adverse effects. In multiple randomized clinical trials in recent years, catheter ablation for atrial fibrillation in patients with heart failure and reduced ejection fraction has shown superiority in improving survival, quality of life, and ventricular function and reducing heart failure hospitalizations compared with antiarrhythmic drugs and rate control therapies. This has resulted in a paradigm shift in management toward nonpharmacological rhythm control of atrial fibrillation in heart failure with reduced ejection fraction. The primary objective of this American Heart Association scientific statement is to review the available evidence on the epidemiology and pathophysiology of atrial fibrillation in relation to heart failure and to provide guidance on the latest advances in pharmacological and nonpharmacological management of atrial fibrillation in patients with heart failure and reduced ejection fraction. The writing committee’s consensus on the implications for clinical practice, gaps in knowledge, and directions for future research are highlighted.
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Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke
Article
  • May 2021
  • NEW ENGL J MED
Background Surgical occlusion of the left atrial appendage has been hypothesized to prevent ischemic stroke in patients with atrial fibrillation, but this has not been proved. The procedure can be performed during cardiac surgery undertaken for other reasons. Methods We conducted a multicenter, randomized trial involving participants with atrial fibrillation and a CHA2DS2-VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating greater risk of stroke) who were scheduled to undergo cardiac surgery for another indication. The participants were randomly assigned to undergo or not undergo occlusion of the left atrial appendage during surgery; all the participants were expected to receive usual care, including oral anticoagulation, during follow-up. The primary outcome was the occurrence of ischemic stroke (including transient ischemic attack with positive neuroimaging) or systemic embolism. The participants, research personnel, and primary care physicians (other than the surgeons) were unaware of the trial-group assignments. Results The primary analysis population included 2379 participants in the occlusion group and 2391 in the no-occlusion group, with a mean age of 71 years and a mean CHA2DS2-VASc score of 4.2. The participants were followed for a mean of 3.8 years. A total of 92.1% of the participants received the assigned procedure, and at 3 years, 76.8% of the participants continued to receive oral anticoagulation. Stroke or systemic embolism occurred in 114 participants (4.8%) in the occlusion group and in 168 (7.0%) in the no-occlusion group (hazard ratio, 0.67; 95% confidence interval, 0.53 to 0.85; P=0.001). The incidence of perioperative bleeding, heart failure, or death did not differ significantly between the trial groups. Conclusions Among participants with atrial fibrillation who had undergone cardiac surgery, most of whom continued to receive ongoing antithrombotic therapy, the risk of ischemic stroke or systemic embolism was lower with concomitant left atrial appendage occlusion performed during the surgery than without it. (Funded by the Canadian Institutes of Health Research and others; LAAOS III ClinicalTrials.gov number, NCT01561651. opens in new tab.)
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