The Convergent Ablation and AtriClip Exclusion of Left Atrial Appendage in Long Standing Persistent Atrial Fibrillation

  

 Atrial  fibrillation (AF) is the most widely recognized cardiovascular  arrhythmia related to expanded morbidity and mortality commonly caused  by stroke or the intensification of heart failure (1,2). Over the  decades, new nonpharmacological treatment modalities acquainted with the  pulmonary vein isolation and exclusion of the left atrial (LA)  appendage have become a reasonable option in contrast to anticoagulation  therapy to lessen the rate of ischemic strokes identified with atrial  fibrillation (2,4). The hybrid convergent ablation to isolate the  pulmonary veins, and the AtriClip exclusion of the LA appendage appear  to be a safe, easily reproducible, feasible, and effective minimally  invasive procedure in long-standing persistent AF. 

 

Steps

1. Under  general anesthesia, a 2 cm midline subxiphoid incision was made. The  xyphoid was preserved and raised to allow entry into the pericardium.
2. A  5 mm PeriCardioScope was utilized to investigate the pericardium cavity  outwardly. The coronary sinus and inferior pulmonary veins were  identified, and sequential superior and inferior transmural ablation was  performed across the back left atrium.
3. A  total of 32 points of ablation were performed utilizing the 3 cm  ablation catheter and 30W RF energy for 90 seconds at each point.
4. Moreover, the baseline temperature (36°C) was monitored with an esophageal probe throughout the procedure.
5. If  the temperature increased by 1°C more than baseline, ablation was  stopped to allow deaeration and until temperatures returned to baseline.
6. Each area had multiple ablations until macroscopically the area was discolored.
7. Following  pulmonary vein (PV) isolation, three left VATS ports (5 mm port in the  second intercostal space (ICS), 5 mm port in the midaxillary line at  fourth ICS, and 12 mm port in the sixth ICS in the posterior axillary)  line were performed.
8. A  double-lumen endotracheal tube was placed prior to the beginning of the  case. The left lung was deflated, and the pericardium was opened  parallel and below the phrenic nerve.
9. The  LA appendage was envisioned and measured, and a 35 mm pro-2 AtriClip  device was deployed through the lower 12 mm port around the base of the  LA appendage.
10. The  patient was in sinus rhythm toward the finish of the hybrid procedure  after having a single direct current cardioversion shock at 200 kj.

References

1. Kaba RA, Momin A, Camm J. Persistent atrial fibrillation: The role of left atrial posterior wall isolation and ablation strategies. J. Clin. Med. 2021; 10:3129.

2. DeLurgio DB, Crossen KJ, Gill J, et al. Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation: Results of CONVERGE Clinical Trial. Circ Arrhythm Electrophysiol. 2020;13(12): e009288.

3. Geršak B, Jan M. Long-Term Success for the Convergent Atrial Fibrillation Procedure: 4-Year Outcomes. Ann Thorac Surg. 2016 Nov;102(5):1550-57.

4. Jiang YQ, Tian Y, Zeng LJ, et al. The safety and efficacy of hybrid ablation for the treatment of atrial fibrillation: A meta-analysis. PLoS One. 2018;13(1): e0190170.