Early outcomes of a novel minimally invasive approach to persistent AF: the convergent AF ablation with simultaneous LARIAT exclusion

Background Atrial fibrillation (AF) is the most prevalent and persistent arrhythmia, with its frequency rising globally. Prevention of stroke resulting from thrombi in the left atrial appendage (LAA) is a crucial pillar in the management of AF. The hybrid convergent approach has been shown to be a safe and effective technique for treating patients with long-standing persistent AF (LSPAF) with superior efficacy to conventional catheter ablation. The LAA is also a critical substrate in the propagation of AF and an anatomical focus for thrombus formation. Epicardial LAA occlusion has several advantages: LAA ligation results in a favourable electrical and structural atrial remodelling, which decreases AF recurrence and stroke reduction. Endocardial ablation alone is not effective for all patients, and emerging evidence demonstrates improved outcomes in patients with persistent AF after a combined hybrid endocardial-epicardial ablation. One approach for LAA exclusion is the catheter-based LARIAT device, which deploys an epicardial suture to ligate the LAA. This can be performed as a standalone percutaneous procedure, but we describe a case series, where this is performed at the same time as a minimally invasive surgical epicardial ablation procedure for AF. Methods and results We describe the treatment of 18 patients (demographics in table) referred for the convergent procedure for AF. Patients were deemed to be suitable for concomitant LARIAT LAA closure following MDT discussion and favourable anatomy on cardiac CT. The procedures were performed between October 2023 - October 2024. A combined procedure was performed. LAA ligation was achieved using the LARIAT system and surgical epicardial AF ablation using the Epi-Sense unipolar vacuum-assisted linear RF-ablation catheter. The median size of LARIAT device used was 50 mm. The procedure was performed in a hybrid theatre and performed by a cardiac surgeon and cardiac electrophysiologist. Patients were then listed for the second stage of the procedure (LA mapping and endocardial catheter ablation). All procedures were concluded without any peri-procedural complications. During 30 day outcomes, there were no major adverse effects. Conclusion The combination of minimally invasive LAA ligation and epicardial ablation was demonstrated to be feasible and safe. This represents a new approach for the treatment of LSPAF in patients with persistent and long-standing persistent AF. In conclusion, the combination of minimally invasive epicardial ablation with simultaneous LARIAT closure of the LAA with staged endocardial ablation revealed to be a safe and feasible approach for the treatment of refractory AF in patients with persistent and long-standing persistent AF.