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.