Hybrid Procedure Overview and Lesion Set
In the Hybrid Convergent procedure (Figure 1), a multidisciplinary heart
care team approach is utilized, first with a surgeon performing an
epicardial ablation and then with an electrophysiologist following with
an endocardial ablation. The minimum aspects of this lesion set involve
electrical isolation of the posterior wall and pulmonary veins, with
esophageal heating mitigated by device design and procedural best
practices. The epicardial ablation procedure is focused on the posterior
wall, utilizing a vacuum-assisted unipolar radiofrequency device
inserted through a cannula with an endoscope. A transdiaphragmatic or
more commonly a subxiphoid approach is used to access the pericardium.
Epicardial ablations are applied across the posterior wall of the left
atrium creating contiguous, parallel lesions. Current convergent
ablation relies on the homogenization of the posterior wall in a more
simplified manner complementary to the endocardial ablation as opposed
to prior versions that were more extensive to replicate a Maze-like
lesion set including a posterior wall box and bi-atrial
lesions.21 Following
the epicardial ablation by the surgeon, endocardial mapping guides the
endocardial ablation performed using an irrigated radiofrequency
catheter by the electrophysiologist, connecting any breakthrough gaps in
lesions and thus completely isolating the left and right pulmonary
veins. Confirmation of isolation is done by evaluating entrance and/or
exit block to ensure the absence of conduction. Most studies on hybrid
convergent procedures relied on commercially available radiofrequency
endocardial catheters. Retrospective single-center and registry analyses
have reported the safety and efficacy of endocardial cryoballoon
catheters in the Hybrid Convergent
procedure.22-24