Staged hybrid procedure in persistent atrial fibrillation: safety, efficacy, and atrial tachyarrhythmia

The only class I recommendations in 2017 expert consensus statement on ablation of atrial fibrillation are catheter ablation of symptomatic paroxysmal atrial fibrillation refractory or intolerant to at least one antiarrhythmic medication and concomitant open surgical ablation (i.e., Cox-maze procedure) of symptomatic atrial fibrillation (1). The outcomes of catheter ablation of persistent and long-standing persistent atrial fibrillation have not been satisfactory (2-6). However, the stand-alone Cox-maze procedure of persistent atrial fibrillation without concomitant cardiac surgery is not recommended because of the risk of complications, including mortality (7,8). The minimally invasive surgical approach using video-assisted pulmonary vein ablation and exclusion of the left atrial appendage was first described in 2005 (9). In addition to potentially more durable pulmonary vein isolation, other advantages of a thoracoscopic approach include access to epicardial structures, such as the ligament of Marshall and ganglionated plexi, management of the left atrial appendage, and avoidance of damaging collateral structures, such as the phrenic nerve and esophagus (1).