Introduction
Atrial fibrillation (AF) is the most common cardiac arrhythmia, with
estimates that over 37 million people were impacted globally in 2017 and
that number is expected to continue to rise. Future estimates of AF
burden predict an increase of over 60% by the year 2050, with 6-12
million patients in the US
alone.1 Not only is AF a
major risk factor for ischemic stroke, but it also causes economic
burden, significant morbidity, and
mortality.1Non-paroxysmal AF, or continuous AF sustained longer than 7 days, is
associated with higher rates of thromboembolism (TE) and mortality
compared to paroxysmal AF based on a meta-analysis of 12
studies.2 Treatment
options for paroxysmal AF include antiarrhythmic drugs (AADs),
cardioversion, and
ablation.3 While the
first line of therapy for paroxysmal AF is often AADs, a meta-analysis
of 6 trials indicated that ablation was more effective and reducing
arrhythmia recurrences and hospitalizations with a similar safety
profile as that of
AADs.4 Unfortunately,
AAD and ablation options for non-paroxysmal AF have lesser and varying
levels of success such that many patients find themselves with long
durations of AF or experience recurrent AF that has to be
re-addressed.5,6Trials have demonstrated improved quality of life with ablation versus
only AADs in patients with non-paroxysmal
AF7, who are typically
patients that have failed AAD treatment, thus leading to decisions on
the type of ablation based on the individual patient’s clinical history
and current clinical picture.
Collaborative heart teams must discuss the individual characteristics
and specifics surrounding each patient with AF seeking care to determine
the best course of
treatment.8 With this
approach, the role of the collaborative heart team is to determine
patient selection based on their need or lack of need for concomitant
surgery, risk/benefit, compliance, and other patient specific factors.
Although AADs are still often the first line of defense, they are
frequently ineffective or poorly tolerated. Options for cardiac ablation
to treat AF have expanded over time, with both approved and emerging
catheter, surgical, and hybrid epicardial-endocardial techniques
supported by clinical evidence. Determining the patient groups most
likely to benefit from each of these approaches allows the
multi-disciplinary team to select the best treatment option for a
particular patient. The focus of this review is on Hybrid Convergent
ablation, a minimally invasive, closed chest combined
epicardial-endocardial approach, and the selection of patients most
appropriate and most likely to benefit from this procedure.