Hybrid epicardial and endocardial ablation of persistent or permanent atrial fibrillation: A new approach for difficult cases

Epicardial AF Ablation. Background: Although percutaneous epicardial catheter ablation (PECA) has been used for the management of epicardial ventricular tachycardia, the use of PECA for atrial fibrillation (AF) has not yet been reported. Objective: To evaluate the efficacy and feasibility of a hybrid PECA and endocardial ablation for AF. Methods: We performed PECA for AF in five patients (48.6 ± 8.1 years old, all male, four redo ablation procedures of persistent AF with a risk of pulmonary vein (PV) stenosis, one de novo ablation of permanent [AF]) after an endocardial AF ablation guided by PV potentials and 3D mapping (NavX). Utilizing an open irrigation tip catheter, a left atrial (LA) linear ablation from the roof to the perimitral isthmus or localized ablation at the junction between the LA appendage and left-sided PVs or ligament of Marshall (LOM) was performed. Results: PECA of AF was successful in all patients with an ablation time of <15 minutes. The left-sided PV potentials were eliminated by PECA in all patients. Bidirectional block of the perimitral line was achieved in two of two patients and a left inferior PV tachycardia with conduction block to the LA was observed during the ablation in the area of the LOM in one patient. A hemopericardium developed in one patient, but was controlled successfully. During 8.0 ± 6.3 months of follow-up, all patients have remained in sinus rhythm (four patients without antiarrhythmic drugs). Conclusion: A hybrid PECA of AF is feasible and effective in patients with redo-AF ablation procedures and at risk for left-sided PV stenosis or who are resistant to endocardial linear ablation.