Overall basics:
- This technique utilizes a cardiothoracic surgeon to perform a surgical ablation and an electrophysiologist to do the catheter ablation.
- First, the cardiac surgeon accesses the heart through a small incision underneath the breastbone and advances a catheter (thin tube) to deliver energy to the epicardium (outside surface of the heart) and perform the surgical ablation on the outside of the heart.
- Then, the electrophysiologist advances catheters into the heart through the groin and does an ablation on the endocardium (inside surface of heart).
- In this fashion, they are interrupting the signals both from the inside and the outside surfaces of the heart.
- This is a newer procedure that is generally done in a staged approach (some do it in a single day) and only certain specialized centers offer this as an option.
- In some centers- they are performing a Hybrid Convergent "Plus" procedure that involves the above procedure plus ablation of the ligament of Marshall and a left atrial appendage clip (LAAC) to further reduce stroke risk and AF burden.
Great article explaining procedure: https://www.uclahealth.org/news/heart-hybrid-ablation-atrial-fibrillation
Single-step hybrid convergent procedure: https://academic.oup.com/ejcts/article/53/suppl_1/i26/4954008
Mayo Clinic Expert Discussion on Hybrid Convergent Procedure: https://youtu.be/Z7k9hb8LwX4
Benefits of procedure:
- Provides better success rates for a patient with LSP AF (long-standing persistent AFib)
- LAAC can be done at the same time which increases success rates to reduce electrical excitability as well as stroke risk reduction.
- Protects the esophagus while doing the Left atrium posterior wall mapping.
Limitations of procedure:
- Some providers do both procedures at the same time, others do them sequentially due to edema that can result from the initial procedure.
- More invasive than catheter ablation alone. This procedure includes a surgical ablation where you will have a small incision on chest.
Staged vs. single-day approach:
Hybrid procedures can be performed staged or in a single day.
- At Cleveland Clinic, they prefer a staged approach, which allows resolution of post surgical acute edema before the endocardial procedure is started and it also enables the epicardial lesions to mature.
- Staging also allows time to determine whether a patient actually needs a second procedure, which can be helpful for patients who have had prior catheter ablations with good control of the pulmonary veins.
Good candidate for hybrid convergent procedure:
- Persistent AF and failure of one or multiple antiarrhythmic drugs
- Failure of multiple ablations
- Severely dilated atria
- Inability to undergo posterior wall ablation due to proximity to the esophagus
General contraindications to procedure:
- Individuals with prior open heart surgery (sternotomy, cardiotomy)
- Individual with prior lung surgeries or left-sided thoracotomy (due to LAAC part of procedure)
- A documented LAA thrombus or significant valvular or coronary heart disease. These findings should prompt an open surgical approach.
Converge Clinical Trial Results- Dr. Delurgio:
Success rates for a patient with LSP AF (long-standing persistent AFib) for more than a year with Hybrid Convergent procedure= 67.7% (w/ AAD meds) & 53.5% (off AAD meds), compared to the success rate of standard catheter ablation for LSP compared to catheter ablations for LSP AF = 50% (w/ AAD meds) & 32% (off AAD meds).
At 18 months using 7-day Holter, 74.0% (53/72) Hybrid Convergent and 55% (23/42) CA patients experienced ≥90% AF burden reduction. A total of 2.9% (3/102) patients had primary safety events within 7 days, and 4.9% (5/102) between 8 and 30 days postprocedure. No deaths, cardiac perforations, or atrioesophageal fistulas occurred. All but one primary safety event resolved.
https://www.ahajournals.org/doi/full/10.1161/CIRCEP.120.009288?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org