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.