Success and outcomes of the convergent procedure for treating persistent atrial fibrillation: a real-world experience

Background: Atrial fibrillation (AF) is common and its prevalence continues to increase. It can cause significant morbidity, healthcare economic burden and detriment to quality of life for its sufferers. Success rates for conventional catheter ablation are suboptimal in persistent AF, especially when longstanding. Long-term anti-arrhythmic use is undesirable and often ineffective. Patients with persistent AF therefore have few genuine options for rhythm control and may be left with debilitating symptoms. Convergent hybrid ablation combines endoscopic surgical epicardial and endocardial catheter ablation to improve the success and durability of ablation. It offers promise in treating persistent AF. Objective: To evaluate the efficacy and safety outcomes of the Convergent procedure for the treatment of Persistent AF. Methods: We performed a retrospective, observational study of patients undergoing ablation from 2012 to 2019 at a single London cardiac centre. Epicardial ablation was performed via mostly subxiphoid access to create posterior wall lesions and partial pulmonary vein isolation (PVI), followed by endocardial ablation to complete PVI and perform additional ablation lesions at the operator’s discretion. Baseline and follow-up data were obtained from procedure reports and clinical notes. Results: 67 patients underwent Convergent ablation. (See Table 1 for baseline and outcome data). A majority had AF longer than 1 year (80.6%) and 49.3% were obese. 19.4% had an ejection fraction of 40% or less. Mean follow up was 2.8 (± 2.0) years. Freedom from AF recurrence was 81.5% at 1 year and 61.5% longer-term. 75.0% of patients had mEHRA symptom class 1 asymptomatic) at 1 year. On multivariate analysis, only increased LA diameter was mildly predictive of longer-term recurrence (p=0.04; OR 1.086; 95% CI, 1.003–1.177). On Kaplain–Meier analysis, patients with AF duration greater than 5 years had a shorter time to AF recurrence (p=0.01) than those with duration under 5 years. 11 patients (16.4%) required redo AF ablation. Complications were: stroke/TIA (n=2) and pseudoaneurysm (n=1). Conclusion: Convergent ablation had good 1-year and longer-term success rates for treating persistent AF. These encouraging results were seen in a challenging cohort with adverse features, who would not traditionally be considered ideal candidates for successful conventional catheter ablation. Our results in a real-world population are in keeping with recent positive results from the