Stepwise endo‐/epicardial catheter ablation for atrial fibrillation: The Mediterranea approach. (12th July 2021)

• Record Type: Journal Article
• Authors: De Martino, Giuseppe; Compagnucci, Paolo; Mancusi, Carmine; Vassallo, Enrico; Calvanese, Claudia; Della Ratta, Giuseppe; Librera, Mariateresa; Franciulli, Marco; Marino, Luigi; Russo, Antonio Dello; Casella, Michela
• Is Part Of: Journal of cardiovascular electrophysiology. Volume 32:Number 8(2021)
• Page Start: 2107
• Page End: 2115
• Publication Date: 2021-07-12
• Subjects: atrial fibrillation -- Bachmann's bundle -- catheter ablation -- endocardial ablation -- epicardial ablation; Blood vessels -- Physiology -- Periodicals; Electrophysiology -- Periodicals; Heart -- Physiology -- Periodicals; 612.1
• DOI: 10.1111/jce.15151
• Languages: English
• ISSNs: 1045-3873

Abstract

Abstract: Background: Outcomes of catheter ablation (CA) among patients with nonparoxysmal atrial fibrillation (AF) are largely disappointing. Objective: We sought to evaluate the feasibility, effectiveness, and safety of a single‐stage stepwise endo‐/epicardial approach in patients with persistent/longstanding‐persistent AF. Methods: We enrolled 25 consecutive patients with symptomatic persistent ( n = 4) or longstanding‐persistent ( n = 21) AF and at least one prior endocardial procedure, who underwent CA using an endo‐/epicardial approach. Our anatomical stepwise protocol included multiple endocardial as well as epicardial (Bachmann's bundle [BB] and ligament of Marshall ablations) components, and entailed ablation of atrial tachycardias emerging during the procedure. The primary outcome was freedom from any AF/atrial tachycardia episode after a 3‐month blanking period. The secondary outcome was patients' symptom status during follow‐up. Results: The stepwise endo‐/epicardial approach allowed sinus rhythm restoration in 72% of patients, either directly ( n = 6, 24%) or after AF organization into atrial tachycardia ( n = 12, 48%). BB's ablation was commonly implicated in arrhythmia termination. After a median follow‐up of 266 days (interquartile range, 96 days), survival free from AF/atrial tachycardia was 88%. Antiarrhythmic drugs could be discontinued in 22 patients (88%). As compared to baseline, more patients were asymptomatic at 9‐month follow‐up (0% vs. 56%, p = .02). Five patients (20%) developed mild medical complications, whereas one subject (4%) had severe kidney injury requiring dialysis. Conclusion: A single‐stage endo‐/epicardial CA resulted in favorable rhythm and symptom outcomes in a cohort of patients with symptomatic persistent/longstanding‐persistent AF and one or more prior endocardial procedures. Epicardial ablation of BB was commonly implicated in procedural success.