Atrial Fibrillation Video Series: Day Eleven
Combining Forces: The Convergent (Hybrid) AF Procedure
We’ve looked at catheter ablation and surgical ablation separately. Now, let’s discuss an approach that blends the best of both worlds – often referred to as a convergent procedure or hybrid ablation. As the name suggests, it’s a convergence of cardiology and cardiac surgery expertise to treat atrial fibrillation, particularly useful in more persistent cases of AF.
What is a convergent procedure? In a convergent approach, a cardiac surgeon and an electrophysiologist (heart rhythm cardiologist) work together, either in the same operation or in stages. The surgeon performs a minimally invasive ablation on the outside of the heart, and the electrophysiologist uses catheters to ablate from inside the heart. By doing both, we aim to create a more extensive and thorough set of ablation lines than either approach alone might achieve.
Here’s how it often works: the surgeon uses a small incision, typically under the breastbone or between the ribs (sometimes even via a tiny incision just below the sternum), to access the outside of the left atrium. Through this, the surgeon can create strategic lesions on the heart’s outer surface – for instance, isolating the pulmonary veins or creating lines on the back wall of the atrium, and usually closing off the left atrial appendage as well. Then, either in the same session or a few weeks later, the electrophysiologist will perform a catheter ablation inside the heart. The EP can then test the electrical signals and touch up any gaps in the lesion lines or address areas that can’t be reached from the outside approach.
By combining forces, the convergent procedure addresses AF from both the epicardial (outside) and endocardial (inside) surfaces. This is especially helpful for long-standing persistent AF, where the atrial tissue may need a more extensive treatment. It reduces the chance that any “missed spots” will let AF recur. Studies have shown that this hybrid approach can improve success rates in difficult AF cases, achieving sinus rhythm in patients who had been in AF for years.
For the patient, a convergent approach may involve a bit more planning – potentially two procedures instead of one. Recovery from the surgical portion is usually quick (since it’s minimally invasive, not open-heart). By adding the catheter portion, we ensure fine-tuning of the results.
Who might be a candidate for convergent ablation? Typically those with persistent or long-standing AF, especially if prior catheter ablations have failed, or if the heart’s atria are enlarged and might need more extensive ablation lines. Your care team will consider factors like your overall health, how long you’ve been in AF, and if you can tolerate a short general anaesthetic, etc.
The idea of two procedures might sound like a lot, but when done in a planned way, many patients tolerate it well and are very satisfied with the outcome – the hope being a durable return to normal rhythm and possibly reducing the need for ongoing antiarrhythmic medications.
Modern AF care is increasingly a team effort. As a surgeon, I often collaborate with my cardiologist colleagues to decide what combination of treatments will give each patient the best shot at a life free of AF. Convergent procedures epitomize that collaborative spirit.
In the next email: We’ll focus on that little pouch we’ve mentioned a few times – the left atrial appendage. Why is it so notorious in AF, and what can we do about it aside from blood thinners? We’ll explore that topic next.
