A narrative review of hybrid ablation for persistent and longstanding persistent atrial fibrillation.

Atrial fibrillation is the most common sustained arrhythmia and is characterized by rapid and irregular atrial activation with loss of atrial contraction. There has been a significant evolution of treatments over the past 30 years. Initially, cardiac surgeons developed approaches via sternotomy with superior efficacy, however early iterations of the procedure were associated with prolonged recovery time and frequent need for pacemaker placement. The current surgical approach to the maze procedure via sternotomy yields excellent efficacy and is a Class 1 recommendation for patients with atrial fibrillation undergoing a concomitant procedure. Several years following the initial development of the surgical maze procedure, cardiac electrophysiologists developed less invasive, however less efficacious catheter ablation options by percutaneous approach. Both the surgical and transcatheter approaches have their advantages and disadvantages with varying risks of complications and efficacy. Through the combination of expertise of cardiac surgeons paired with the electrophysiology team, a hybrid ablation procedure has been developed offering an increased efficacy with a less-invasive approach than the current gold standard treatment of Cox-maze IV procedure. This review will discuss the hybrid ablation procedure, review recent associated clinical trials, and discuss advantages and challenges associated with this multidisciplinary approach for management of patients with AF.

Comprehensive Intraprocedural Unfractionated Heparin Protocol During Catheter Ablation of Atrial Fibrillation in the Presence of Direct Oral Anticoagulants and Wide Spectrum of Body Mass Index.

INTRODUCTION: Data on optimal dosing of unfractionated heparin (UFH) in the presence of a direct oral anticoagulant (DOAC) to achieve and maintain an activated clotting time (ACT) of ≥300 seconds during catheter ablation of atrial fibrillation (CA-AF) are limited and prevalence of obesity adds to the unpredictable response to UFH. METHODS AND RESULTS: One hundred seventeen consecutive patients undergoing CA-AF were prospectively administered weight-adjusted, weight-based UFH using a pre-specified detailed protocol and retrospectively analyzed. Due to lack of distribution of UFH into muscle or adipose tissue and lower degree of vascularity in the latter compartment, each patient's ideal and actual weights were used to determine the adjusted-weight for use in all UFH doses. A UFH bolus of 200 units/kg was administered intravenously followed by an infusion of 35 units/kg/hour. The mean age was 65 years, and 85 patients (72.6%) were male. The average body mass index (BMI) was 30 (range 18-50) kg/m2. After the initial UFH bolus dose, 99 patients (84.6%) achieved ACT ≥300 sec with a mean (± SD) of 380 ± 79 sec. The mean time to reach an ACT ≥300 in all patients was 14.6 ± 12.4 minutes. Among all measured ACT values, 423 (90.8%) were ≥300 seconds. These results were consistent within all BMI categories. There were no intraprocedural thrombotic or hemorrhagic complications. Two patients (1.7%) sustained groin vascular access site hematoma without subsequent intervention and 7 patients (6%) experienced minor oozing post-procedurally. CONCLUSIONS: Our comprehensive weight-adjusted, weight-based UFH protocol, during CA-AF in presence of a DOAC, rapidly achieved and maintained an effective ACT irrespective of BMI.

Use of an active-fixation coronary sinus lead to implant a biventricular pacemaker via the femoral vein.

Cardiac resynchronization therapy, which involves the placement of a pacing lead in the right atrium and in each ventricle, is effective in treating heart failure that is caused by left bundle branch block and cardiomyopathy. The left ventricular lead is usually placed into a lateral branch of the coronary sinus via the subclavian route. When the subclavian route is unavailable, insertion of a standard, passive-fixation coronary sinus lead via the femoral approach is feasible; however, the likelihood of subsequent dislodgment is high. Herein, we describe the placement of a novel, self-retaining, active-fixation coronary sinus lead--the Attain StarFix Model 4195 OTW Lead--in an elderly heart-failure patient, via the femoral approach. We believe that this is the 1st report of this procedure.

Use of a unique long pre-curved sheath to facilitate femoral placement of coronary sinus catheters.

METHODS: Catheterization of the coronary sinus (CS) from the femoral vein is widely used during electrophysiologic procedures. Access to the CS may be difficult. To address this problem we explored the utility of a long pre-formed (SAFL) sheath in a cohort of consecutive patients requiring CS cannulation in the electrophysiology laboratory. This unique sheath has distal curvatures in 2 planes, potentially facilitating CS cannulation. RESULTS: 68 patients were studied with an average age of 63+/- 16 years. In twelve patients (18%), standard femoral CS cannulation was ineffective. In six of these patients, the SAFL sheath allowed for cannulation, and in six the subclavian approach was required. There were no significant differences in age, left ventricular ejection fraction, or echocardiographically estimated pulmonary artery systolic pressure between the various subgroups. There was a trend towards a larger left atrial size in the atrial flutter group (46mm+/- 7.9) versus all others (40.6mm+/- 6.3, P=.076). Left atrial size was 37 mm in the femoral sheath-requiring group versus 44 mm in all others (P=NS). CONCLUSION: Utilization of a unique commercially available long preformed sheath helps to provide femoral CS catheter access in selected cases in the electrophysiology laboratory.

Thoracoscopic microwave epicardial ablation: feasibility for the treatment of idiopathic sinus node tachycardia.

Inappropriate sinus tachycardia is a potentially debilitating condition with tachycardia emanating from the sinus node region. Endocardial radiofrequency energy ablation is the current preferred mode of treatment for symptomatic medication failures. Phrenic nerve damage can result from this procedure. We report a case in which the potential for phrenic nerve damage was avoided by using a thoracoscopic approach to displace the phrenic nerve posteriorly and perform epicardial microwave ablation. This resulted in the successful treatment of a patient with highly symptomatic inappropriate sinus tachycardia.

The prevalence of cardiac ectopy in elderly patients with echocardiographically normal hearts is not increased by significant coronary artery disease.

ISSUE: A higher frequency of abnormal heart rhythms has previously been shown in elderly subjects with overtly normal hearts as demonstrated by noninvasive testing. However, no prior study on elderly patients with echocardiographically structurally normal hearts has distinguished cardiac dysrhythmia incidence based on the presence or absence of angiographically documented coronary artery disease (CAD). METHODS: We performed 24-hour ambulatory monitoring on patients with no coronary stenosis of greater than 30% and normal left ventricular (LV) systolic function by angiography. This group was then compared with a group of elderly patients with normal LV systolic function and at least one major coronary artery stenosis of 70% or greater. All patients had echocardiographically normal LV wall thickness and systolic function and no significant valvular disease. RESULTS: The experimental group was composed of 15 patients with CAD aged 71 +/- 6 years. The control group without significant CAD was composed of 20 patients aged 73 +/- 4 years (P = not significant [NS]). There was no difference with respect to prevalence of hypertension, use of calcium-channel blockers, and history of smoking. There was no difference between the groups with regard to the number of premature atrial contractions (467 +/- 759 [experimental] vs 672 +/- 1789 [control]; P = NS); premature ventricular contractions (359 +/- 599 [experimental] vs 290 +/- 858 [control]; P = NS); and prevalence of ventricular couplets, ventricular tachycardia, paroxysmal atrial fibrillation, and supraventricular tachycardia (all P = NS). CONCLUSIONS: These findings indicate that the prevalence of cardiac dysrhythmias in elderly patients with echocardiographically normal hearts is not influenced by the presence of angiographically significant CAD.