The Convergent Ablation and AtriClip Exclusion of Left Atrial Appendage in Long Standing Persistent Atrial Fibrillation

Atrial fibrillation (AF) is the most widely recognized cardiovascular arrhythmia related to expanded morbidity and mortality commonly caused by stroke or the intensification of heart failure (1,2). Over the decades, new nonpharmacological treatment modalities acquainted with the pulmonary vein isolation and exclusion of the left atrial (LA) appendage have become a reasonable option in contrast to anticoagulation therapy to lessen the rate of ischemic strokes identified with atrial fibrillation (2,4). The hybrid convergent ablation to isolate the pulmonary veins, and the AtriClip exclusion of the LA appendage appear to be a safe, easily reproducible, feasible, and effective minimally invasive procedure in long-standing persistent AF.

Steps

1. Under general anesthesia, a 2 cm midline subxiphoid incision was made. The xyphoid was preserved and raised to allow entry into the pericardium.
2. A 5 mm PeriCardioScope was utilized to investigate the pericardium cavity outwardly. The coronary sinus and inferior pulmonary veins were identified, and sequential superior and inferior transmural ablation was performed across the back left atrium.
3. A total of 32 points of ablation were performed utilizing the 3 cm ablation catheter and 30W RF energy for 90 seconds at each point.
4. Moreover, the baseline temperature (36°C) was monitored with an esophageal probe throughout the procedure.
5. If the temperature increased by 1°C more than baseline, ablation was stopped to allow deaeration and until temperatures returned to baseline.
6. Each area had multiple ablations until macroscopically the area was discolored.
7. Following pulmonary vein (PV) isolation, three left VATS ports (5 mm port in the second intercostal space (ICS), 5 mm port in the midaxillary line at fourth ICS, and 12 mm port in the sixth ICS in the posterior axillary) line were performed.
8. A double-lumen endotracheal tube was placed prior to the beginning of the case. The left lung was deflated, and the pericardium was opened parallel and below the phrenic nerve.
9. The LA appendage was envisioned and measured, and a 35 mm pro-2 AtriClip device was deployed through the lower 12 mm port around the base of the LA appendage.
10. The patient was in sinus rhythm toward the finish of the hybrid procedure after having a single direct current cardioversion shock at 200 kj.

References

1. Kaba RA, Momin A, Camm J. Persistent atrial fibrillation: The role of left atrial posterior wall isolation and ablation strategies. J. Clin. Med. 2021; 10:3129.
2. DeLurgio DB, Crossen KJ, Gill J, et al. Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation: Results of CONVERGE Clinical Trial. Circ Arrhythm Electrophysiol. 2020;13(12): e009288.
3. Geršak B, Jan M. Long-Term Success for the Convergent Atrial Fibrillation Procedure: 4-Year Outcomes. Ann Thorac Surg. 2016 Nov;102(5):1550-57.
4. Jiang YQ, Tian Y, Zeng LJ, et al. The safety and efficacy of hybrid ablation for the treatment of atrial fibrillation: A meta-analysis. PLoS One. 2018;13(1): e0190170.

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