ISMICS 2024 Annual Meeting

Convergent 3 is a first-in-human lesion set that addresses persistent arrhythmia following hybrid posterior wall isolation utilizing endocardial/epicardial (EN/EP) ablation via a subxiphoid and left video-assisted thoracoscopic surgery (VATS) entry. This newly described approach adds left atrial appendage (LAA) management & interrupts pathways supporting left macro-reentrant flutter; a frequent driver for AF recurrence.

Patients with non-paroxysmal AF had staged hybrid procedure incorporating the modified lesion set:

-During the epicardial portion, a left atrial posterior wall (LAPW) ablation was performed with unipolar radiofrequency through subxiphoid incision

-Contiguous lesions were created between the pulmonary veins (PVs)

-A left-sided VATS approach was used to interrupt ligament of Marshall (LOM) and exclude the LAA with clip

-Epicardial ablation catheter used to begin an anterior mitral line adjacent to left PV and LAA (Figure 1C)

-During endocardial ablation, PV isolation and roof line were created

-Epicardial anterior mitral line was then connected to the mitral annulus with endocardial ablation

-Electroanatomic ultrasensitive map (EUM) was performed documenting transmuralityand integrity of linear lesions using wavefront propagation mapping

-All patient were followed with implantable loop recorders

A total of 18 patients with non-paroxysmal AF had the modified ablation technique. The cohort was 61.1% male, mean age 74.4 years, mean left atrial diameter 4.1cm, and 33% had prior ablation.

Figure 1 shows placement of epicardial ablation line extending from left superior PV (LSPV) adjacent to LAA base and endocardial line constructed using RF catheter to mitral annulus.

Figure 1. Placement of Epicardialand Endocardial ablation linesand voltage EUM results

A.EUM showing scar from combinedEN/EP posterior wall ablation

B.EUM showing ablation scar fromLSPV to LAA to mitral annulus

C.Complete lesion set (PV, posteriorwall, LAA ligation, hybrid mitral line)

A voltage EUM demonstrated transmural scar extending from LSPV/LAA to mitral annulus shown in Figure 1A inset. Using an AF burden threshold of <5%, 91% of patients remained free of atrial arrhythmias at 12 months. No macroreentrantflutters were recorded during follow-up, and no complications were observed.

Prior Hybrid Convergent AF ablation techniques have been disadvantaged by the inability to address annular flutters or the LAA. The described Convergent 3 approach includes LAA exclusion while addressing targets known to trigger/sustain AF in non-paroxysmal AF using a comprehensive ablation strategy that is efficient and transmural. The lesion set incorporates multiple sites, including PV isolation, roof line, cavotricuspid line, LOM, electrical isolation of LAA and LAPW, and first ever described mitral annular line using an EN/EP approach.

Makati: AtriCure (consulting, speaking, research, advisory); Boston Scientific (consulting, speaking, research, advisory); Siemens (consulting, speaking/teaching); Medtronic (Speaking/teaching). Sherman: AtriCure (consulting, speaking, research, advisory). Cox: AtriCure (consulting, speaking and teaching). Marcie Meador, PhD (AtriCure, Inc) provided editing and formatting assistance under the direction of the authors.

ISMICS 2024 Annual Meeting

Convergent 3: Novel Hybrid Af Ablation Lesion Set & Laa Exclusion Using Subxiphoid, Left Thoracoscopic Epicardial/endocardial Approach

Poster Presenter

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Convergent 3: Novel Hybrid Af Ablation Lesion Set &#38; Laa Exclusion Using Subxiphoid, Left Thoracoscopic Epicardial/endocardial Approach

Poster Presenter

Authors

Part of Topic

Convergent 3: Novel Hybrid Af Ablation Lesion Set & Laa Exclusion Using Subxiphoid, Left Thoracoscopic Epicardial/endocardial Approach