title: Hybrid epicardial and endocardial ablation of persistent or permanent atrial fibrillation: a new approach for difficult cases.
abstract: BACKGROUND
  Although percutaneous epicardial catheter ablation (PECA) has been used for the management of epicardial ventricular tachycardia, the use of PECA for atrial fibrillation (AF) has not yet been reported.
  
  
  OBJECTIVE
  To evaluate the efficacy and feasibility of a hybrid PECA and endocardial ablation for AF.
  
  
  METHODS
  We performed PECA for AF in five patients (48.6 +/- 8.1 years old, all male, four redo ablation procedures of persistent AF with a risk of pulmonary vein (PV) stenosis, one de novo ablation of permanent [AF]) after an endocardial AF ablation guided by PV potentials and 3D mapping (NavX). Utilizing an open irrigation tip catheter, a left atrial (LA) linear ablation from the roof to the perimitral isthmus or localized ablation at the junction between the LA appendage and left-sided PVs or ligament of Marshall (LOM) was performed.
  
  
  RESULTS
  PECA of AF was successful in all patients with an ablation time of <15 minutes. The left-sided PV potentials were eliminated by PECA in all patients. Bidirectional block of the perimitral line was achieved in two of two patients and a left inferior PV tachycardia with conduction block to the LA was observed during the ablation in the area of the LOM in one patient. A hemopericardium developed in one patient, but was controlled successfully. During 8.0 +/- 6.3 months of follow-up, all patients have remained in sinus rhythm (four patients without antiarrhythmic drugs).
  
  
  CONCLUSIONS
  A hybrid PECA of AF is feasible and effective in patients with redo-AF ablation procedures and at risk for left-sided PV stenosis or who are resistant to endocardial linear ablation.
authors.affiliation: Korea University Cardiovascular Center, Seoul, Republic of Korea.
authors.forename: Hui-Nam
authors.initials: HN
authors.lastname: Pak
authors.forename: Chun
authors.initials: C
authors.lastname: Hwang
authors.forename: Hong Euy
authors.initials: HE
authors.lastname: Lim
authors.forename: Jin Seok
authors.initials: JS
authors.lastname: Kim
authors.forename: Young-Hoon
authors.initials: YH
authors.lastname: Kim
mesh_terms: D001281:Atrial Fibrillation / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D003131:Combined Modality Therapy; D004699:Endocardium / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium / Q000601:surgery*; D016896:Treatment Outcome