Long-Standing Persistent AF
The progression of AF from paroxysmal to long-standing persistent AF is
characterized by advanced substrate remodeling of the left atrium in a
stretch, inflammation, and fibrosis sequence leading to
fibrillation.25 Thus,
in advanced AF, the predominant triggers have evolved from the pulmonary
vein to left atrial tissue, particularly on the posterior wall, creating
a need for treatment options beyond endocardial ablation to effectively
and comprehensively treat long-standing persistent
AF.26,27Success rates of endocardial ablation in this population have had
limited effectiveness, ranging from 35.6 to 43% after a single
procedure.26,27This is attributed to the lack of a standardized lesion set, limited
ability to produce transmural lesions, and dissociation of electrical
activity between the endocardium and epicardium. A subgroup analysis
examining the effectiveness of the Hybrid Convergent procedure for
long-standing persistent AF demonstrated an absolute difference of
28.8% (78% improvement; p=0.022) in 12-month freedom from AF in the
Hybrid group over the endocardial only group and was sustained through
18-months.28 The
benefit of Hybrid Convergent held when compared to the Catheter Ablation
arm and their respective impacts on AF burden reduction as well as
freedom from cardioversion and AF symptoms, through 18-months. Along
with an acceptable safety profile, these significantly improved outcomes
provided the collaborative heart team a new, effective approach for the
difficult to treat population of patients suffering from advanced AF.