Minimally Invasive Convergent Hybrid AF Ablation Technique

Convergent hybrid AF ablation is a safe and effective minimally invasive procedure for treating persistent atrial fibrillation. It combines epicardial radiofrequency left atrial posterior wall ablation through subxiphoid access, concomitant thoracoscopic left atrial appendage management, and pre/postprocedural transcatheter pulmonary vein isolation.

In this video, the authors demonstrate a successful convergent procedure in a sixty-nine-year-old normosthenic male patient suffering from persistent atrial fibrillation despite previous pulmonary vein isolations and electrical cardioversions.



First, the patient was placed in a supine position with double-lumen tube intubation. Prior to skin incision, a temperature probe was placed in the esophagus and verified by fluoroscopy at the level of the left atrial posterior wall. The procedure began with a 2-3 cm subxiphoid incision for exposure of the pericardium. As the pericardium was opened, the EPi-Sense trocar together with a 5 mm endoscope were placed behind the left atrial posterior wall and the pulmonary veins were visualized. The EPi-Sense ablation catheter was then introduced via the trocar under camera vision and unipolar cooled ablation lines were performed one by one for 90 seconds each until the entire posterior wall was transmurally ablated (1). The subxyphoid skin incision was then closed.

Next, a thoracoscopic left atrial appendage closure was performed through three ports within the intercostal space. Two 5 mm ports and one 12 mm port were placed on the left side of the chest with an endoscopic clip device. The size of the clip and the intercostal space access were determined by preoperative CT scan measurements. Since correct positioning of the clip on the LAA basis with no residual pouch was confirmed by transesophageal echocardiography, the clip was released and subtotal excision of the appendage for decompression was performed (2). A 20 Charriere chest tube was then inserted via the 12 mm port into the pleural cavity and left in place for 48 hours. The patient was extubated on the operating table and transferred to the recovery room for six hours.

References

1. DeLurgio DB, Crossen KJ, Gill J et al. Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation: Results of CONVERGE Clinical Trial. 2020 Dec;13(12):e009288. doi: 10.1161/CIRCEP.120.009288. Epub 2020 Nov 13.
2. Cartledge R, Suwalski G, Witkowska A, Gottlieb G, Cioci A, Chidiac G, Ilsin B, Merrill B, Suwalski P. Standalone epicardial left atrial appendage exclusion for thromboembolism prevention in atrial fibrillation. Interact Cardiovasc Thorac Surg. 2022 Mar 31;34(4):548-555. doi: 10.1093/icvts/ivab334. PMID: 34871377; PMCID: PMC8972304.

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