64 Non-concomitant Hybrid Ablation Using the Novel Cobra Fusion RF Device Provides Promising Medium Term Outcomes in The Treatment of Longstanding Persistent Atrial Fibrillation

Abstract

Background Outcomes for catheter ablation of long-standing persistent atrial fibrillation (LsPsAF) are inferior to those of paroxysmal atrial fibrillation and the optimal ablation strategy remains unclear. We describe our experience of non-concomitant hybrid ablation for LsPAF using a novel surgical RF ablation system. Methods Thefirst surgical stage is performed via a right-sided video assisted thoroscopic approach (VATS). The suction based Cobra Fusion RF system (Atricure Inc, West Chester, OH) is used to ablate a 'box lesion' and isolate the left atrial posterior wall (LAPW). Patients then return for a staged endocardial mapping procedure with catheter ablation to complete the 'box', treat atrial arrhythmia and create a cavo-tricuspid isthmus line. Results Thirty-five patients underwent a VATS procedure with ablation performed in 33 (2 having dense pericardial adhesions). One patient had a fatal CVA post operatively and 5 patients developed transient phrenic nerve palsy. 32 patients (28M/4F) are therefore currently under follow-up: (all values median), age - 65, CHADSVASc - 2, BMI - 30, Left atrial diameter -46.5mm, LVEF -55%, total AF duration - 30 months. Following epicardial ablation acute LAPW isolation with entrance and exit block was demonstrated in 53%. Twenty-one patients have undergone the 2nd catheter stage after a median of 142 days. The baseline rhythm was sinus rhythm (SR) in 24%, AF in 52% and A. Flutter in 24%. 33% had LAPW isolation at baseline (Figure 1) with further ablation isolating the LAPW (figure 2) in all except one patient, 1 patient required a mitral isthmus line, and 1 patient ablation for right atrial tachycardia. All patients were discharged in SR. Sixteen patients have greater than 3 month's follow-up (median - 13 months) post 2nd stage with ECG, clinical review and 7 day ambulatory monitoring at 4, 12 and 24 months. 15 (93%) remain in SR. Three patients required DCCV in the first 3 months and 3 remain on anti-arrhythmic drugs. (Figure presented) Conclusions Non-concomitant hybrid AF ablation provides excellent medium term outcomes in the treatment of longstanding persistent atrial fibrillation. Long-term outcomes of the technique and randomised study comparing with catheter ablation alone are needed.