Chasnoyt. Results of hybrid technology in the treatment of non-paroxysmal atrial fibrillation

Based on the analysis of immediate and long-term results of treatment of a randomized cohort of patients with idiopathic non-paroxysmal atrial fibrillation, the safety and effectiveness of minimally invasive biatrial epicardial bipolar radiofrequency ablation both in the format of hybrid treatment in combination with endocardial ablation of pulmonary veins and in a stand-alone variant have been shown.

Aim: To evaluate the effectiveness of hybrid and staged treatment of idiopathic persistent atrial fibrillation (AF) by analyzing immediate and long-term (2 years) treatment results in a single-center randomized clinical controlled trial.

Methods. A single-center randomized trial included 33 patients with non-paroxysmal AF. All patients underwent minimally invasive video-assisted epicardial radiofrequency ablation (RFA) as the first procedure in accordance with Patent for invention of the Republic of Belarus № 22432 dated 12.06.2016. "The method of bipolar minimally invasive epicardial radiofrequency ablation in patients with isolated persistent atrial fibrillation". Depending on the distribution of the group, the patient received an endocardial ablation procedure either during the current hospitalization, or in the period 3-6 months after the epicardial stage in case of recurrence of atrial arrhythmia (Atrial Fibrillation/Atrial Flutter). The primary endpoints included the frequency of AF recurrence at the hospital stage, the frequency of sinus rhythm retention (SR) at the end of hospitalization, the need for pacemakers, the frequency of major adverse cardioand cerebrovascular events (MACCE). Secondary endpoints included retention of SR at the end of observe, the need to take class I/III antiarrhythmic drugs (AAD) and anticoagulants outside the "blind" period, as well as the need for repeated procedures.

Results. There were no differences in the results between the groups for the primary endpoints. By the time of discharge from the hospital, sinus rhythm (SR) occurred in 100 % of patients. We did not observe major adverse cardiovascular and cerebrovascular events at the hospital stage. AF paroxysms at the end of the study period in patients using class I/III AAD were observed in 2 (13.33 %) cases in the "hybrid" group and 2 (11.1 %) cases in the "staged" treatment group. The need for repeated procedures for atrial arrhythmias was 2 (13.3 %) cases in the "hybrid" treatment group and 5 (27.78 %) cases in the "staged" treatment group. The cumulative mid-term SR retention rate at 1 year was 94.5 % in both groups; after 2 years, the rate was 86.7 % in the "hybrid" treatment group and 88.9 % in the "staged" group.

Conclusion. Epicardial bipolar biatrial ablation has shown high efficacy in the treatment of non-paroxysmal forms of AF, but often requires repeated procedures to eliminate typical atrial flutter. To perform more effective pulmonary veins isolation, it is reasonable to perform separate pulmonary vein ablation in addition to antral ablation. The staged treatment of persistent forms of AF is justified from the clinical and economic point of view.

1. Zhyhalkovich A. Minimally invasive epicardial ablation in atrial fibrillation: evolution of methods. Cardiology in Belarus, 2020, vol. 12 (3), pp. 409–418. doi: 10.34883/PI.2020.12.3.013 (in Russian).

2. Boersma L.V., Castella M., van Boven W. et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial. Circulation, 2012, vol. 125, pp. 3–30. doi: 10.1161/CIRCULATIONAHA.111.074047.

3. Huang H., Wang Q., Xu J., Wu Y., Xu C. Comparison of catheter and surgical ablation of atrial fibrillation: A systemic review and meta-analysis of randomized trials. Thoracic Cardiovascular Surgery, 2022, vol. 163 (3), pp. 980–993. doi: 10.1016/j.jtcvs.2020.04.154.

4. Pokushalov E., Romanov A., Elesin, D. et al. Catheter versus surgical ablation of atrial fibrillation after a failed initial pulmonary vein isolation procedure: a randomized controlled trial. J Cardiovasc Electrophysiol, 2013, vol. 24(12), pp. 1338–1343. doi: 10.1111/jce.12245.

5. Kot tkamp H, Hindrick s G. Beyond pulmonar y vein isolation: the issue of reconduction. J Cardiovasc Electrophysiol, 2009, vol. 20, pp. 1388–1390. doi: 10.1111/j.1540-8167.2009.01581.x.

6. Sy R.W., Gula L.J., Leong-Sit P. et al. Complete antral encirclement is not required for pulmonary vein isolation. Heart Rhythm, 2011, vol. 8, pp. 16–22. doi: 10.1016/j.hrthm.2010.09.069.

7. Gerstenfeld E.P., Callans D.J., Dixit S., Zado E., Marchlinski F.E. Incidence and location of focal atrial fibrillation triggers in patients undergoing repeat pulmonary vein isolation: implications for ablation strategies. J Cardiovasc Electrophysiol, 2003, vol. 14(7), pp. 685–690. doi: 10.1046/j.1540-8167.2003.03013.x.

8. Zhyhalkovich A. Hybrid surgery for atrial fibrillation: view of cardiac surgeon. Cardiology in Belarus, 2016, vol. 8(2), pp. 230–237. (in Russian).

9. Pak H.N., Hwang C., Lim H.E., Kim J.S., Kim Y.H. Hybrid epicardial and endocardial ablation of persistent or permanent atrial fibrillation: a new approach for difficult cases. J Cardiovasc Electrophysiol, 2007, vol. 18(9), pp. 917–923. doi: 10.1111/j.1540-8167.2007.00882.x.

10. Krul S.P., Driessen A.H., van Boven W.J. Thoracoscopic video-assisted pulmonary vein antrum isolation, ganglionated plexus ablation, and periprocedural confirmation of ablation lesions: first results of a hybrid surgical electrophysiological approach for atrial fibrillation. Circ Arrhythm Electrophysiol, 2011, vol. 4(3), pp. 262–270. doi: 10.1161/CIRCEP.111.961862.

11. Mahapatra S., LaPar D.J., Kamath S. et al. Initial experience of sequential surgica l e picardial-catheter endocardial ablation for persistent and long-standing persistent atrial fibrillation with long-term follow-up. Ann Thorac Surg, 2011, vol. 91(6), pp. 1890–1898. doi: 10.1016/j.athoracsur.2011.02.045.

12. Kurfirsta V., Mokráčeka A., Bulavab A. et al. Two-staged hybrid treatment of persistent atrial fibrillation: short-term single-centre results. Interactive CardioVascular and Thoracic Surgery, 2014, vol. 18(4), pp. 451–456. doi: 10.1093/icvts/ivt538.

13. Pison L., Gelsomino S., Lucà F. et al. Effectiveness and safety of simultaneous hybrid thoracoscopic and endocardial catheter ablation of lone atrial fibrillation. Ann Cardiothorac Surg, 2014, vol. 3(1), pp. 38–44. doi: 10.3978/j.issn.2225-319X.2013.12.10.

14. Kumara N., Pisona L., La Meirb M. et al. Hybrid approach to atrial fibrillation ablation using bipolar radiofrequency devices epicardially and cryoballoon endocardially. Interact Cardiovasc Thorac Surg, 2014, vol. 19(4), pp. 590–594. doi: 10.1093/icvts/ivu189.

15. Sapelnikov O.V., Nikolaeva O.A., Ardus D.F. et al. One-stage hybrid treatment of persistent atrial fibrillation. Russian journal of cardiology and cardiovascular surgery, 2018, vol. 11(6), pp. 83–86. doi: 10.17116/kardio20181106183. (in Russian).

16. Zhyhalkovich A., Zhmailik R. Long-term results of minimally invasive epicardial videoassisted radiofrequency isolation of pulmonary veins in isolated atrial fibrillation. Emergency cardiology and cardiovascular risks, 2022, vol. 6(1), pp. 1459–1465. doi: 10.51922/2616-633X.2022.6.1.1459. (in Russian).

17. Van Laar C., Kelder J., van Putte B.P. The totally thoracoscopic maze procedure for the treatment of atrial fibrillation. Interact Cardiovasc Thorac Surg, 2017, vol. 24(1), pp. 102–111. doi: 10.1093/icvts/ivw311.

18. Vos L.M., Kotecha D., Geuzebroek G.S.C. et al. Totally thoracoscopic ablation for atrial fibrillation: a systematic safety analysis. Europace. 2018, vol. 20(11), pp. 1790–1797. doi: 10.1093/europace/eux385.

19. Pidanov O.Yu., Tsepenshchikov V.A., Shcherbatyuk K.V. et al. Thoracoscopic aablation in a treatment of patients with lone atrial fibrillation. Annals of arrhythmology, 2017, vol. 14(4), pp. 190–198. doi: 10.15275/annaritmol.2017.4.2. (in Russian).

20. Richardson T.D., Shoemaker B.M., Whalen S.P., et al. Staged versus simultaneous thoracoscopic hybrid ablation for persistent atrial fibrillation does not affect time to recurrence of atrial arrhythmia. J Cardiovasc Electrophysiol, 2016, vol. 27(4), pp. 428–443. doi: 10.1111/jce.12906.

21. Van der Heijden C.A.J, Vroomen M, Luermans JG, et al. Hybrid versus catheter ablation in patients with persistent and longstanding persistent atrial fibrillation: a systematic review and meta- analysis. Eur J Cardiothorac Surg, 2019, vol. 56(3), pp. 433–443. doi: 10.1093/ejcts/ezy475.

22. Varzaly J.A., Lau D.H., Chapman D. et al. Hybrid ablation for atrial fibrillation: A systematic review and meta-analysis. JTCVS Open, 2021, vol. 16(7), pp. 141–154. doi: 10.1016/j.xjon.2021.07.005.

23. Bulava A.J. Hybrid procedures for persistent atrial fibrillation: necessity and timing of the catheter ablation stage. Thorac Dis, 2018, vol. 10(1), E83-E86. doi:10.21037/jtd.2017.12.11.

24. On Y.K., Park K.M., Jeong D.S. et al. Electrophysiologic results after thoracoscopic ablation for chronic atrial fibrillation. Ann Thorac Surg, 2015, vol. 100(5), pp. 1595– 1603. doi: 10.1016/j.athoracsur.2015.04.127.

25. Pearman C.M., Poon S.S., Bonnett L.J. et al. Minimally Invasive Epicardial Surgical Ablation Alone Versus Hybrid Ablation for Atrial Fibrillation: A Systematic Review and Meta-Analysis. Arrhythm Electrophysiol Rev, 2017, vol. 6(4), pp. 202–209. doi:10.15420/aer/2017.29.2.