Appeal type: Experimental/Investigational
Decision: Overturned

Cardiac
Surgical services

This patient has a long-standing history of atrial fibrillation (status/post (s/p) ablation X2, subsequently had AVN ablation with placement of a permanent pacemaker) had recently been admitted with symptomatic atrial fibrillation. The patient was started on Tikosyn and converted. On outpatient follow-up, the patient complained of fatigue, headaches, and exertional dyspnea with minimal exertion. The patient thought self was in atrial fibrillation. This was confirmed on device interrogation. Transesophageal echocardiogram  showed normal LV size and low normal systolic function with estimated ejection fraction (EF) of 50 to 55%, normal right ventricular size with normal right ventricular systolic function, mild aortic valve regurgitation, mild mitral valve regurgitation, mild tricuspid valve regurgitation, no thrombus seen in left atrial appendage/LA/RA. Nuclear stress test  showed that myocardial perfusion imaging failed to reveal evidence for ischemia, small mild fixed perfusion defect at the basal inferior wall segment, nondiagnostic stress electrocardiogram (ECG) due to ventricular pacing, normal LV size and systolic function, transient ischemic dilation is not apparent. Patient was on carvedilol for rate control, Tikosyn for rhythm control, and warfarin for stroke prevention. The patient was referred for a hybrid procedure because of the continuing symptoms. The health plan's determination regarding the proposed health service or treatment is overturned in whole. Atrial fibrillation (AF) is the most common cardiac arrhythmia and has been found to be a major contributor to stroke and mortality. Hospitalizations for AF have increased 2- to 3-fold over the past several years. The incidence of AF increases with age and is associated with increased stroke, heart failure and mortality. Persistent and long standing persistent AF (as in this patient) is difficult to treat and often refractory to medical therapy and catheter ablation. Patients with persistent or long-standing persistent AF often require endocardial catheter ablation (as in this patient), which in addition to pulmonary vein isolation, can include radiofrequency catheter ablation (RFA) of fractionated electrograms and linear lesions. Reported success rates for these procedures vary, but the rates are usually much lower in patients with persistent AF when compared with patients with paroxysmal AF. Enlarged left atria, which are often associated with persistent or long-standing persistent AF, may form the electrophysiologic substrate needed to maintain this arrhythmia. The posterior left atrial (LA) wall is a common target for ablation in these patients. Therapeutic ablation for AF has evolved significantly with progressive advancements in technology and surgical instruments. With the goal of minimizing surgical morbidity while maintaining the benefits of the traditional Cox-Maze procedure, surgical ablation for AF has undergone significant modifications. An increased understanding of substrate complexity, predominantly in patients with persistent or long-standing persistent AF, has led to the development of a synergistic hybrid approach (recommended in this patient.) The hybrid approach attempts to combine the benefits of epicardial ablation and catheter-based endocardial ablation in order to overcome the shortcomings associated with each technique alone Among patients with persistent AF (as in this patient), hybrid ablation is associated with less AF recurrence and fewer re-do ablations. In addition to a potentially more durable lesion set, other advantages of an epicardial approach include access to epicardial structures such as the ligament of Marshall and GP, management of the LAA, and avoidance of damaging collateral structures, such as the PN and esophagus. The hybrid procedure has a higher success rate shown by significantly fewer incidences of arrhythmia recurrence at follow-up and less need for repeat ablation, as well as a longer time to recurrence.