title: Initial experience of sequential surgical epicardial-catheter endocardial ablation for persistent and long-standing persistent atrial fibrillation with long-term follow-up.
abstract: BACKGROUND
  Patients with long-standing persistent (LSP) atrial fibrillation (AF) who have previously undergone catheter ablation represent a challenging patient population. Repeat catheter ablation in these patients is arduous and associated with a high failure rate, whereas surgical ablation can be complicated by multiple flutters. We sought to determine if minimally-invasive surgical ablation, followed by catheter ablation of all inducible flutters, would improve success rates over repeat catheter ablation alone.
  
  
  METHODS
  Fifteen patients (Sequential) with persistent or LSP AF who failed at least one catheter ablation and one anti-arrhythmic drug (AAD) underwent surgical ablation, followed by planned endocardial evaluation and catheter mapping with ablation during the same hospitalization. Sequential patients were matched to 30 patients who had previously failed at least one catheter ablation and underwent a repeat catheter ablation (catheter-alone). The primary end point was event-free survival of any documented AF recurrence or AAD use.
  
  
  RESULTS
  All patients underwent uncomplicated surgical ablation and electrophysiology procedure. Five Sequential patients had seven inducible flutters that were mapped and ablated. After a mean follow-up of 20.7±4.5 months, 13/15 (86.7%) Sequential patients, but only 16/30 (53.3%) catheter-alone patients, were free of any atrial arrhythmia and off of AAD (p=0.04). On AAD, 14/15 (93.3%) Sequential patients were free of any atrial arrhythmia recurrence, compared to 17/30 (56.7%) catheter-alone patients (p=0.01).
  
  
  CONCLUSIONS
  For patients with atrial fibrillation who have failed catheter ablation, Sequential minimally invasive epicardial surgical ablation, followed by endocardial catheter-based ablation, has a higher early success rate than repeat catheter ablation alone.
authors.affiliation: Department of Medicine, University of Virginia, Charlottesville, Virginia 22908-0679, USA.
authors.forename: Srijoy
authors.initials: S
authors.lastname: Mahapatra
authors.forename: Damien J
authors.initials: DJ
authors.lastname: LaPar
authors.forename: Sandeep
authors.initials: S
authors.lastname: Kamath
authors.forename: Jason
authors.initials: J
authors.lastname: Payne
authors.forename: Kenneth C
authors.initials: KC
authors.lastname: Bilchick
authors.forename: James M
authors.initials: JM
authors.lastname: Mangrum
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium; D012086:Reoperation