At Boston AF, two poster presentations showed that a multidisciplinary procedure that uses both epicardial and endocardial ablation (convergent procedure) is associated with high single procedure efficacy in a patient population dominated by persistent atrial fibrillation and is a viable treatment option for restoring sinus rhythm in patients with persistent atrial fibrillation and enlarged atria.
The aim of the convergent procedure is to be a treatment alternative to patients with atrial fibrillation who have failed previous ablation procedures or who have enlarged atria (>4.5cm), and it uses the skills of both the cardiovascular surgeon and the electrophysiologist. The procedure starts with a cardiovascular surgeon creating bi-atrial lesion patterns epicardially without the need for chest incisions, which is then followed by an electrophysiologist completing the lesion pattern endocardially with catheter ablation. The convergent procedure, which was developed by physicians, has been made possible by the use of nContact’s coagulation technology (EPi-Sense and Numeris with VisiTrax).
In Borut Gersak, head of department, Department of Cardiovascular Surgery, University Medical Center Ljubljana, Slovenia, and colleagues’ poster, 50 patients with atrial fibrillation underwent the convergent procedure either as a single-setting procedure (34) or as a staged procedure (16). All patients were then fitted with an implantable cardiac monitor (Reveal XT, Medtronic). At the end of the 24-month study, 87% of all patients were in sinus rhythm and 67% were in sinus rhythm and off antiarrhythmic drugs. Gersak et al concluded: “This prospective study demonstrated the convergent procedure is a viable treatment option to restore sinus rhythm in persistent patients with enlaged atria.” They added that the study also showed that continuous monitoring with the Reveal XT monitors “highlighted the long-term freedom from atrial fibrillation after combining the epicardial creation of linear lesions with endocardial isolation of the pulmonary veins.”
Keith Golden, St Vincent Hospital, Indianapolis, Indiana, USA, and colleagues reviewed the convergent procedure in 115 patients. Patients were followed-up with 72-hour holter monitoring at least six months after the procedure. After an average follow-up of 11.4 months, 84% of patients were in sinus rhythm and 64% were in sinus rhythm and off antiarrhythmic drugs.
Golden et al concluded: “In this mulitcentre study, the convergent procedure demonstrated a high single procedure efficacy even in a population predominated by persistent atrial fibrillation.” They also found that the complication rates were similar to those observed with traditional atrial fibrillation ablation.
Gersak said: “The convergent procedure (hybrid procedure) should be considered the best available treatment option for the patients with persistent atrial fibrillation and enlarged atria. The convergent procedure data presented at the 2012 Boston AF Symposium was monitored at the highest level with the Reveal XT continuous 24-hour loop recorder and the results were exceptional even when compared to other technologies which were evaluated under less scrutiny. This new level of monitoring sets a high standard for the evaluation of atrial fibrillation treatments. Because of the procedure’s ability to meet these standards, we have adopted the convergent procedure at our hospital as primary treatment for patients with enlarged atria.”
