The hybrid ablation approach to treating long-standing persistent atrial fibrillation: real-world data from a tertiary institution

Abstract Background Maintenance of sinus rhythm is challenging in patients with longstanding persistent atrial fibrillation (PeAF). Minimally invasive surgical AF ablation may improve outcomes when combined with catheter ablation (the hybrid convergent ablation). This real world data series evaluates the safety and efficacy of the convergent procedure in longstanding PeAF. Methods 91 consecutive patients with longstanding PeAF underwent subxiphoid endoscopic ablation of the posterior left atrium followed by catheter ablation from 2013 to 2022 at a single tertiary within the dedicated hybrid theatre. Median age was 64.4 years with a BMI of 30.3kg/m2. Median duration of AF was 50.4 months with an LA diameter of 45.7mm. The primary outcome was AF-free survival at 12 months; secondary outcomes included change in EHRA class, echocardiographic data, procedural complications, freedom from anti-arrhythmic drugs (AADs), and long term arrhythmia-free survival. All patients underwent 72 Holter monitoring at 3 months and then 12 months post procedure with an echocardiogram at baseline and then at 12 months. Holter monitoring at 6 months was dependant on clinical status. Results After 12 months, the convergent procedure was associated with increased AF-free survival on AADs (65.3%) and off AADs (43.5%). Allowing for multiple procedures, after 32.3 ± 12.7 months' follow-up the convergent procedure was associated with arrhythmia-free survival on AADs (48.4%) and off AADs (33.7%). Complication rates were 4.3% until 2018 over the first 5 year data outcomes, followed by 1.2% with no major complications over the next 5 years following a change from subdiaphragmatic access to subxiphoid access and increased operator experience. Conclusions In longstanding Persistent AF, the convergent procedure is associated with improved arrhythmia-free survival. Complication rates over time have improved due to changes in the access and operator experience.