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By Jeko Madjarov, MD and Sherry J. Saxonhouse, MD

Patients with persistent and long-standing persistent atrial fibrillation (AF) have limited options when medical therapy and catheter ablation fails. Surgical AF ablation is generally considered a last resort and only done when another operation, such as a coronary bypass or valvular replacement, is necessary.

Without effective treatment, AF patients can experience ongoing issues including an increased risk of stroke and heart failure. But the tide is turning thanks to hybrid AF ablation, an innovative procedure that combines surgical and catheter ablation. Hybrid AF ablation (also known as the convergent procedure) reduces complications, shortens recovery time, and has significantly better success rates than catheter-based ablation in patients with long-standing persistent AF and persistent AF.

Risks of Catheter Ablation and Surgical Ablation

Radiofrequency ablation is the frontline therapy for many AF patients, especially in patients with paroxysmal AF, as well as some patients with persistent AF. The risks involved with this procedure are limited and less than 1% overall. A rare complication of catheter-based ablation is formation of a left atrial (LA) esophageal fistula which may be life-threatening if emergent surgical intervention is not available.

Surgical procedures, like the Cox-Maze or mini maze, are more invasive and involve thoracoscopic incisions in both chest walls. This exposes patients to long periods of anesthesia, lengthens recovery time and increases the risk of complications.

Combining the Best of Both Approaches

Hybrid ablation is a great option for patients with long-standing persistent AF who have failed medical therapy and repeat ablations. During the procedure, a surgeon and electrophysiologist work together in a hybrid ablation room to perform the ablation from inside the heart (endocardial) and outside of the heart (epicardial). This dual approach increases the likelihood that the posterior wall is isolated from the rest of the heart with a transmural lesion set. Using epicardial posterior wall ablation versus endocardial ablation minimizes the risk of LA esophageal fistula.

Initially, the surgeon makes a 3 cm subxiphoid incision to access the pericardium. Lesions are then applied to the posterior left atrium. Then the electrophysiologist completes the endocardial ablation and performs mapping to make sure the targeted electrical signals have been isolated.

Faster Recoveries, Better Outcomes

Hybrid AF ablation usually takes five to six hours. Combining the procedures means patients only go through anesthesia and recovery once. Patients typically go home within two to three days and experience less pain and scarring than if they underwent surgical ablation.

More important, hybrid AF ablation has been shown to have better results for patients with long-standing persistent AF. The success rate of catheter ablation is around 40-50%. With hybrid ablation, up to 80% of patients achieve normal sinus rhythm. And one study reported that 79% of hybrid ablation patients remained arrhythmia-free after three years.

The Sanger Advantage

Sanger Heart & Vascular Institute performed our first hybrid AF ablation in June 2018 and we’re still the region’s only center offering this procedure. Our team has performed over 20 hybrid AF ablation procedures to date, and all but two of those patients had undergone earlier interventions that failed. Today, every patient is living arrhythmia-free.

To learn more or refer a patient, call 877-999-7484.

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