First Preliminary Results of a New Hybrid Approach to Treat Persistent Atrial Fibrillation: The Convergent Procedure Together with Left Atrial Appendage Electrical Isolation/Closure

Objectives: Due to the low success rate of catheter based atrial fibrillation (AF) ablation, persistent atrial fibrillation yields a combined hybrid approach of catheter based and surgically based AF ablation. As a new “hybrid approach,” catheter based pulmonary vein isolation in combination with endoscopic surgical ablation of the posterior left atrial wall (the “convergent procedure”) has been introduced.

In most recent literature, the base of the left atrial appendage has been described as an additional source of electrical foci, causing atrial fibrillation, especially in persistent AF patients. We present the first unique preliminary results of performing the hybrid Convergent procedure in combination with epicardial left atrial appendage electrical isolation and closure.

Methods: Eleven patients (3 females [27.2%], mean age: 60.8 years) were treated with the Convergent procedure (minimally invasive subxiphoid epicardial ablation of the posterior wall of the left atrium). A concomitant epicardial beating heart left atrial appendage electrical isolation and occlusion surgery was performed with a clip device. First 2 (18.2%) LAA clippings were performed via left-sided minithoracotomy, thereafter 9 (81.8%) consecutive patients were treated exceptionally thoracoscopically.

Mean BMI was 30.1± 3.8, mean CHA2DS-VASC score: 2.7 ± 1.5 and mean HAS-BLED score 1.5 ± 0.65. A persistent AF was detected in 6 patients (54.5%) and a long-lasting persistent AF (>1 year duration) in 5 patients (45.5%).

Result: No neurological events occurred in any of the patients. One (9.1%) major bleeding occurred due to injury of a small diaphragmatic artery branch. At discharge nine (81.8%) patients revealed a sinus rhythm, and two (18.2%) patients showed normofrequent atrial fibrillation (in one patient, pulmonary vein isolation was still pending). The mean follow-up is currently 167.7 ± 111.6 days. At last follow-up, 72.7% of patients received antiarrhythmic drug treatment and 81.8% of patients were in sinus rhythm (catheter-based PVI pending in one patient).

Conclusion: The hybrid convergent AF ablation approach in conjunction with epicardial beating heart electrical LAA isolation and closure, preferably thoracoscopically, is a feasible and a safe procedure with a low complication rate and reveals a high success rate of sinus rhythm restoration.

Publication History

Article published online:
19 February 2021