Abstract
Background: Outcomes of catheter ablation (CA) among patients
with non-paroxysmal atrial fibrillation (AF) are largely disappointing.
Objective: We sought to evaluate the feasibility,
effectiveness, and safety of a single-stage stepwise endo-/epicardial
approach in patients with persistent/longstanding-persistent AF.
Methods: We enrolled 25 consecutive patients with symptomatic
persistent (n=4) or longstanding-persistent (n=21) AF and at least one
prior endocardial procedure, who underwent CA using an endo-/epicardial
approach. Our anatomical stepwise protocol included multiple endocardial
as well as epicardial (Bachmann’s bundle [BB] and ligament of
Marshall ablations) components, and entailed ablation of atrial
tachycardias emerging during the procedure. The primary outcome was
freedom from any AF/atrial tachycardia episode after a 3-month blanking
period. The secondary outcome was patients’ symptom status during
follow-up.
Results: The stepwise endo-/epicardial approach allowed sinus
rhythm restoration in 72% of patients, either directly (n=6, 24%) or
after AF organization into atrial tachycardia (n=12, 48%). BB’s
ablation was commonly implicated in arrhythmia termination. After a
median follow-up of 266 days (interquartile range, 96 days), survival
free from AF/atrial tachycardia was 88%. Antiarrhythmic drugs could be
discontinued in 22 patients (88%). As compared to baseline, more
patients were asymptomatic at 9-month follow-up (0% vs- 56%, p=0.02).
Five patients (20%) developed mild medical complications, whereas one
subject (4%) had severe kidney injury requiring dialysis.
Conclusion: a single-stage endo-/epicardial CA resulted in
favorable rhythm and symptom outcomes in a cohort of patients with
symptomatic persistent/longstanding-persistent AF and one or more prior
endocardial procedures. Epicardial ablation of BB was commonly
implicated in procedural success.
Key words: atrial fibrillation, catheter ablation, epicardial
ablation, endocardial ablation, Bachmann’s bundle