title: Hybrid Procedure (Endo/Epicardial) versus Standard Manual Ablation in Patients Undergoing Ablation of Longstanding Persistent Atrial Fibrillation: Results from a Single Center.
abstract: Ablation of longstanding persistent atrial fibrillation (LSPAF) is the most challenging procedure in the treatment of AF, either by surgical or by percutaneous approach.
  
  
  
  We investigated the difference in success and complication rates between combined surgical epicardial and endocardial catheter ablation procedure and our standard endocardial ablation procedure.
  
  
  
  Twenty-four consecutive patients (group 1) with LSPAF and enlarged left atrium (>4.5 cm) underwent a combined procedure, consisting of surgical, closed-chest, epicardial, radiofrequency ablation (nContact, NC, USA) via pericardial access, and concomitant endocardial ablation (hybrid procedure). Procedural complications and long-term outcomes were compared to those of 35 consecutive patients who refused the hybrid procedure and underwent standard endocardial only ablation (group 2). Baseline characteristics were comparable. In group 1, 1 patient (4.2%) developed post-procedural cardio-embolic stroke and 3 (12.5%) died (1 atrio-esophageal fistula, 1 fatal stroke, 1 of unknown cause in early follow-up), while no strokes or deaths occurred in group 2. Overall complication rates were higher for group 1 (P = 0.036). At 24-month follow-up, 4 (19%) patients in group 1 and 19 (54.3%) in group 2 were arrhythmia-free after a single procedure, on or off antiarrhythmic drugs (P<0.001). Total procedural time (276.9 ± 63.5 vs. 203.15 ± 67.3 minutes) and length of hospital stay (5 [IQR 3-8] vs. 1 [IQR 1-3] days were significantly shorter for group 2 (P <0.001).
  
  
  
  In patients with LSPAF and enlarged left atrium, a concomitant combined surgical/endocardial ablation approach increases complication rate and does not improve outcomes when compared to extensive endocardial ablation only.
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Zachary
authors.initials: Z
authors.lastname: Edgerton
authors.affiliation: Department of Heart and Vessels, University of Florence, Florence, Italy.
authors.forename: Alessandro Paoletti
authors.initials: AP
authors.lastname: Perini
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Rodney
authors.initials: R
authors.lastname: Horton
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Chintan
authors.initials: C
authors.lastname: Trivedi
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.|Hospital of the University of Pennsylvania, Pennsylvania, USA.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Santangeli
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.|Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
authors.forename: Rong
authors.initials: R
authors.lastname: Bai
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.|University of Milan, Milan, Italy.
authors.forename: Carola
authors.initials: C
authors.lastname: Gianni
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Sanghamitra
authors.initials: S
authors.lastname: Mohanty
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: G Joseph
authors.initials: GJ
authors.lastname: Gallinghouse
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Javier E
authors.initials: JE
authors.lastname: Sanchez
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Shane
authors.initials: S
authors.lastname: Bailey
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Maegen
authors.initials: M
authors.lastname: Lane
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.|University of Foggia, Foggia, Italy.|Albert Einstein College of Medicine at Montefiore Hospital, New York, USA.
authors.forename: Luigi
authors.initials: L
authors.lastname: DI Biase
authors.affiliation: University of Foggia, Foggia, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Santoro
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
authors.forename: Justin
authors.initials: J
authors.lastname: Price
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.|Department of Internal Medicine, Dell Medical School, Austin, Texas, USA.|California Pacific Medical Center, San Francisco, California, USA.|Interventional Electrophysiology, Scripps Clinic, San Diego, California, USA.|Division of Cardiology, Stanford University, Palo Alto, California, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D000200:Action Potentials; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D018572:Disease-Free Survival; D004699:Endocardium / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006325:Heart Atria / Q000503:physiopathology / Q000601:surgery*; D006339:Heart Rate; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010496:Pericardium / Q000503:physiopathology / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology; D012008:Recurrence; D012307:Risk Factors; D013781:Texas; D013997:Time Factors; D016896:Treatment Outcome
keywords: atrial fibrillation; catheter ablation; endocardial approach; hybrid procedure; longstanding persistent atrial fibrillation; surgery; unipolar surgical ablation