The EP Perspective: Should We Do Hybrid Ablation, and Who Should We Do It On? L. Pison, MD PhD FESC AATS Surgical Treatment of Arrhythmias and Rhythm Disorders November 17-18, 2017 Miami Beach, FL, USA
Consultancy Atricure Roche Biosense Webster Research grant Atricure Medtronic Disclosures
Case #1 Male, 55y Persistent AF Sotalol 80mg bid CHADS-VASC: 0 Normal LV function, LA 40mm/66cc
What would you suggest? 1. Switch to flecainide 2. Endocardial PVI (STAR-AF II) 3. Hybrid AF ablation
Case #2 Male, 45y Dilated cardiomyopathy, paroxysmal AF CRT-D (EF 25% 38%) LA 55mm/114cc PVI with cryo 12/2015 Amiodarone
What would you suggest? 1. Redo endocardial PVI (PV reconnection ) 2. Thoracoscopic AF ablation (box and LAA occlusion) 3. Hybrid AF ablation (box, LAA occlusion and endocardial check)
Case #2 Hybrid procedure 5/2017: A pace, V pace PVI, boxleasion, LAA exclusion
Quadripolar catheter in the box
Quadripolar catheter in the box
Bidirectional block? 1. Yes 2. No 3. Not sure Pison et al. JAFIB 2013
The ideal ablation procedure for AF isolate the PVs permanently defines the specific properties of the underlying atrial electrical substrate in order to customize the subsequent ablation strategy always create completely transmural (linear) lesions minimally invasive
Cox-maze III procedure > 90% restoration of sinus rhythm Mortality rate 2% Stroke risk virtually eliminated Sinus node dysfunction in 5-10% Prasad et al, J Thorac Cardiovasc Surg 2003
Cox-maze IV vs minimally-invasive epicardial surgical ablation Damiano R et al. J Thorac Cardiovasc Surg 2011 Krul S et al. Int J Cardiol 2013
Microwave Irrigated bipolar RF Melby S et al. J Thorac Cardiovasc Surg 2006 Melby S et al. J Thorac Cardiovasc Surg 2006
Importance of evaluating conduction block in RF ablation for AF Gersak B et al. Eur J Cardiothorac Surg 2012
Hybrid AF ablation Hybrid AF surgical ablation procedure is defined as a joint AF ablation procedure performed by electrophysiologists and cardiac surgeons either as part of a single joint procedure or performed as two pre-planned separate ablation procedures separated by no more than six months of time. EP Cardiac surgery Calkins et al, Heart Rhythm 2012
Advantages of the hybrid AF approach Driver K, Mangrum M. Journal of Thoracic Disease 2015
FAST trial 124 patients with AAD refractory AF with LA dilatation and hypertension (42 patients, 33%) or failed prior CA (82 patients, 67%) Randomized to catheter ablation or non-ep guided thoracoscopic surgical ablation CA: linear antral PVI and optional additional lines. SA: bipolar RF isolation of the bilateral PV, GP ablation, and LAA excision with optional additional lines. Boersma et al. Circulation 2012
Boersma et al. Circulation 2012
Pison et al. Europace 2012
Selection criteria [1] previously failed CA [2] failure of at least one antiarrhythmic drug (AAD) [3] left atrial (LA) volume 29 ml/m2 [4] persistent or longstanding persistent AF [5] patient preference for a hybrid procedure instead of a percutaneous approach Pison L, La Meir M et al. JACC 2012
Pison L, Maesen B, La Meir et al. Unpublished data
Pison L, Maesen B, La Meir et al. Unpublished data
Time to redo procedure was 346±227 days 9% of PVs were reconnected 7% of box lesions were incomplete Velagic et al. J Cardiovasc Electrophysiol 2016
Pison, La Meir et al. JACC 2012
One- or two-stage approach One-stage: surgery and EP during the same procedure Two-stage: Sequential: EP later but during the same hospital admission Staged: EP in a second hospital admission Vroomen, Pison. J Interv Card Electrophysiol 2016
Staged versus Simultaneous Thoracoscopic Hybrid Persistent AF Ablation 83 patients 52 same-day 31 staged (median delay 75 days) 23 patients (29%) with recurrence at median 147 days Postoperative monitoring with ILR Richardson et al. J Cardiovasc Electrophysiol 2016
Richardson et al. J Cardiovasc Electrophysiol 2016
Richardson et al. J Cardiovasc Electrophysiol 2016
Surgical techniques Thoracoscopic approach: Monolateral or bilateral thoracic Subxiphoideal Transabdominal transdiaphragmatic Energysource: cryo, unipolar or bipolar RF Vroomen, Pison. J Interv Card Electrophysiol 2016
Lesion set Pison et al. JAFIB 2013
Prospective randomized trials CEASE-AF (NCT02695277) HARTCAP-AF (NCT02441738)
Dipole density mapping
Three critical conduction patterns identified with AcQMap Dipole Density mapping Driver Maintainer Maintainer LSPV LSPV LSPV LAA LIPV RSPV LAA LIPV RSPV RSPV LAA RIPV RIPV RIPV MV MV MV Focal Localized Rotational Activation (spirals around a confined zone) Localized Irregular Activation (enters and exits a confined zone) (both with multiple directions from collision and block) 39
Conclusions Hybrid ablation: the best of two worlds
Conclusions Hybrid ablation: the best of two worlds Redo after CA and/or (longstanding) persistent AF
Conclusions Hybrid ablation: the best of two worlds Redo after CA and/or (longstanding) persistent AF More multicenter randomized data are necessary