Endo-epicardial strategy in persistent and long standing persistent AF: comparing AF binary-Burden outcomes and clinical implications

Background Recent studies suggest that combining endo-epicardial approaches are a promising strategy for persistent and longstanding persistent atrial fibrillation at ECG/holter monitoring. Studies on AF burden after endo-epicardial ablation for non paroxysmal AF are scanty. Objective To evaluate atrial fibrillation recurrence as binary variable and burden by continuous rhythm monitoring after an endo-epicardial ablative strategy in patients with symptomatic persistent long standing persistent AF. Methods Patients with symptomatic non paroxysmal AF were treated with a first transcatheter or thoracoscopic ablation followed by a thoracoscopic or transcatheter respectively step within 6-9 month from recurrence. All patients were monitored with a loop recorder. EHRA questionnaire was used for classification pre procedure and at follow up. Results Eighty-nine patients with symptomatic persistent , long standing persistent AF (male 85.3%, mean age 62.5±8.8, mean atrial volume 120.4±29.5ml, mean± AF duration 3.9±1.4years, mean burden pre 83.5%±12.2%) were enrolled. AF freedom as binary variable at 6,12,24,36months was respectively 88.8%,86.6%,75.5%,69.5% on ECG/Holter, and 84.2%68.5%,64%,48.5% at ILR monitoring. At the same timeline mean burdens were respectively 0.4±1.9%,0.4±2.9%,1.1±3.9%,0.3±1.6%.Success rate based upon a burden threshold <0.1% was 94.3%,90.9%,90.2% and 74.2% respectively, and 95.2%,94.4%,90.2,88.6% with threshold <5%. Hospitalization for cardiovascular events was 8.9%.All re-hospitalization with burden >0.1%. EHRA class pre ablation was :2.2%(IIa),20.8(Iib),52.8%(III),16.8%(IV), among those wth recurrence at ILR ditribution post was :45.7%classI, 21.1%class Iia, 21.2% IIb,9%class III, 3% class IV. Conclusion An endo-epicardial strategy for symptomatic persistent and long standing persistent AF not only reduces AF recurrence as binary outcome but achieves significant reduction of AF burden and re-hospitalization rates at mid-term follow up.binary recurrence at 3 yearsburden at three years <0.1%