Future directions
There are several factors that a multi-disciplinary hybrid team, led by the partnership between the electrophysiologist and cardiac surgeon, should consider when assessing a patient for potential Hybrid Convergent treatment. First, the care team should ensure that it is comprised of several specialists working together to promote a robust AF care team model to optimize care of this patient population. There should be a referral process in place that transitions patients from the single electrophysiologist practitioner to this shared care team model that is expanded to also include cardiac surgeons and cardiovascular anesthesiologists, among others, where each member provides individual expertise. The Hybrid Convergent procedure does not come without risks, so several patient factors must be assessed, such as chronicity of AF, left atrial size, and other comorbidities. If the efficacy of the procedure is expected to be low and the risks high, other treatment options may be considered first. If other treatment options have been tried and were not successful or there has been a recurrence of AF, the team may weigh the potential benefits of the Hybrid convergent procedure greater than the potential risks of the procedure itself or the risks of other or no treatment.
As previously mentioned, additional, larger studies could evaluate the potential arrhythmia and thromboembolic benefit as well as any risks associated with LAA exclusion in a hybrid convergent procedure. This would be helpful to guide further procedural and patient selection best practices for closing the LAA in the context of hybrid ablation. Matched comparisons of patients who had prior ablation and those who received de novo Hybrid Convergent ablation would help determine how successful the procedure is for patients outside of the CONVERGE trial target population. While CONVERGE allowed left atrial size up to 6.0 cm, the enrolled patient population had mildly enlarged left atrium. Upper limits for left atrial size have been established for open surgical ablation based on the rhythm benefit achieved, however it is currently unknown how Hybrid Convergent outcomes correlate with incremental increases in left atrial size.