The hybrid ablation approach to treating long-standing persistent atrial fibrillation: real-world data from a tertiary institution
Authors: Lim V G , Hwang T , He H J , Jesani H , Dandekar U , Barker T , Osman F 
Published: May 2024

Abstract

Background
Pulmonary vein isolation(PVI) is effective treatment for atrial fibrillation(AF) but efficacy of endocardial ablation-alone for long-standing persistent AF is limited(1). Hybrid AF ablation may offer better outcomes but studies were on patients with paroxysmal/persistent-AF(2) and relied on Holter-alone to assess recurrences(3). Our hybrid-AF ablation patients were all long-standing persistent cases and monitored with implantable loop recorders(ILR).

Aim
Evaluate long-term outcomes of hybrid-AF ablation using ILR data.

Methods
The hybrid approach at our institution consisted of a first-stage minimally invasive surgical epicardial ablation of the left atrial posterior wall via radiofrequency (RF) ablation. An ILR was implanted at the same setting. A few months later, the second-stage endocardial catheter ablation was performed to ensure PVI and ‘touch-up’ of any residual conduction gaps in the left atrium. All epicardial ablation cases were performed at the cardiothoracic operating-room in our tertiary hospital (‘hub’) whilst the endocardial RF-cases were performed at either the hub or satellite centre(‘spoke’) as part of our institution’s ‘hub-and-spoke’ model. Inclusion criteria for hybrid AF-ablation were long-standing persistent AF, body mass index (BMI) &lt;40 and standard indications for AF ablation as per ESC 2020 AF guidelines(4). Once both aspects of the hybrid approach were completed, patients were followed up in ILR remote monitoring clinics. AF recurrence was defined as AF/atrial tachycardia(AT) lasting &gt;30s. All data were obtained retrospectively via hospital electronic patient records.

Results
38 consecutive patients completed both aspects of hybrid ablation between December 2017-August 2023 with mean follow up of 19±13months(mean±SD). Baseline data, procedure characteristics and details of complications are shown in Table 1. ILR data was obtained in 36/38 patients(ILR implantation precluded in one due to previous breast cancer surgery. One had ILR battery depletion contributed by significant delay between the 2 stages of the hybrid ablation). AF/AT recurred in one third of patients during the blanking period(3 months) whilst 45% remained in sinus rhythm at 1-year; at 2yrs, 39% maintained SR and 25% at 3yrs (Figure 1). Post-hybrid ablation, two patients underwent re-do AF/AT ablation. The relatively high recurrence rate compared to other studies may be due to: very long duration of AF prior to hybrid-ablation(7.0±3.6years), significant delay between both stages of the procedure(9±11months) due to the pandemic and competing waiting list pressures, multiple comorbidities (82% had &gt;2 comorbidities, 42% were obese) and the higher arrhythmia pickup rate with ILRs compared with intermittent rhythm monitoring.

Conclusion
Our study provides real world insight into the challenges of delivering a hybrid AF ablation service but highlights its utility in long-standing persistent AF patients.Table 1Figure 1