Subxiphoid Hybrid Approach for Epicardial/Endocardial Ablation and LAA Exclusion in Patients with Persistent and Longstanding Atrial Fibrillation

Abstract

Two patients with long-standing atrial fibrillation (AF) refractory to medical management and with prior pulmonary vein isolation underwent a new hybrid epicardial/endocardial subxyphoid approach for AF ablation and left atrial appendage (LAA) ligation. Pulmonary vein and LA posterior wall isolation, as well as LAA exclusion were achieved in both patients. There were no procedural complications. Both patients remain in sinus rhythm. Both patients are off antiarrhythmic medications.

Keywords: Atrial Fibrillation; Hybrid epicardial/endocardial ablation; LAA ligation.

Figures

Figure 1.. LAA ligation. Selective lung ventilation, rightward rotation of the table and gentle medial retraction of the heart with a malleable retractor (panel A) allows for direct visualization of the LAA and passage of the LARIAT snare over the LAA (panel B). The arrow highlights the snare around the LAA. TEE is used to assess capture of all the lobes. Panel C and E represent pre-ligation LAA of 2D and 3D TEE images, respectively. 2-D (panel D) and 3-D (panel F) TEE assessment of LAA closure 7 weeks post-LAA ligation verified permanent LAA closure.

Figure 2.. Voltage maps. Voltage maps prior to endocardial ablation demonstrates areas of residual voltage in the anterior aspect of the LSPV and RSPV (panel A, AP view) and small islands of normal voltage on the posterior aspect of the LA (panel B, PA view). Panel C (AP view) and panel D (PA view) demonstrate the endocardial ablation lesions (2 mm lesions). Red indicates voltage 5 V. Gray indicates no signals (ie scar).