Hybrid ablation for persistent atrial fibrillation: a narrative review

Figures

• 

  Figure 1. Benefits of catheter and surgical ablation. Combining catheter ablation using RF energy with surgical ablation may lead to improved lesion durability, as either one alone might not provide sufficient durability. The advantages of surgical ablation include the capability for intervention in the left atrial appendage and treatment of the vein of Marshall, which is difficult to treat by catheter ablation. On the other hand, the advantages of catheter ablation include the detailed evaluation of endocardial potentials using 3D mapping systems, which allows for the identification and treatment of reconnection gaps after surgical ablation. Additionally, point ablation for non-PV foci is possible. LAA, left atrial appendage; VOM, vein of Marshall; GP, ganglionated plexi; MI line, mitral isthmus line; SVC-IVC line, superior vena cava-inferior vena cava line; PV, pulmonary vein.

• 

  Figure 2. Representative case 1. Staged catheter ablation after stand-alone surgical ablation. A patient in his 50s with long-standing persistent AF. Thoracoscopy-guided surgical ablation was performed, including PVI, posterior wall isolation, superior vena cava isolation, and left atrial appendage excision. After discharge, atypical atrial flutter was documented. Five months later, staged catheter ablation was conducted. Reconnection was observed in the left pulmonary veins and left atrial posterior wall. Roof line and partial floor line ablation were performed, resulting in left atrial posterior wall re-isolation. The floor line, which was in close proximity to the esophagus, had lesions extending to the endocardial side due to surgical ablation, and additional endocardial ablation to the vicinity of the esophagus was not necessary. The left pulmonary veins were re-isolated by additional ablation only for the anterior carina. The uncommon atrial flutter was identified as peri-mitral atrial flutter, and mitral isthmus ablation was performed. Cavo-tricuspid ablation was also conducted. It has been over five years since the hybrid ablation, and the patient has maintained normal sinus rhythm…

• 

  Figure 3. Representative case 2. Staged catheter ablation after stand-alone surgical ablation. A patient in her 60s with persistent AF, a history of direct closure surgery for atrial septal defect, and a history of treatment for right pleural empyema. Thoracoscopy-guided AF surgery was performed, including left PVI, roof line ablation, floor line ablation, and left atrial appendage excision. Surgical isolation of the right pulmonary veins was impossible due to pleural adhesions. Six months later, staged catheter ablation was performed, such as isolation of the right pulmonary veins, along with roof line and partial floor line ablation. Without additional endocardial ablation close to the esophagus, left atrial posterior wall re-isolation was achieved. Re-isolation of the superior vena cava and cavo-tricuspid isthmus ablation were also conducted. LAO, left anterior oblique; PA, posterior anterior; SVCI, superior vena cava isolation; RPVI, right pulmonary vein isolation; CTI line, cavo-tricuspid isthmus line; AF, atrial fibrillation; PVI, pulmonary vein isolation.