Atrial fibrillation (AF), the most common cardiac arrhythmia is associated with increased morbidity and mortality. The higher mortality is due to the risk of heart failure and cardioembolic events. This in-depth review focuses on the strategies and efficacy of catheter ablation for non-paroxysmal atrial fibrillation. The main medical databases were searched for contemporary studies on catheter ablation for non-paroxysmal AF. Catheter ablation is currently proven to be the most effective treatment for AF and consists of pulmonary vein isolation as the cornerstone plus additional ablations. In terms of SR maintenance, it is less effective in non-paroxysmal AF than in paroxysmal patients. but the clinical benefit in non-paroxysmal patients is substantially higher. Since pulmonary vein isolation is ineffective, a variety of techniques have been developed, e.g. linear ablations, ablation of complex atrial fractionated electrograms, etc. Another paradox consists in the technique of catheter ablation. Despite promising results in early observation studies, further randomized studies have not confirmed the initial enthusiasm. Recently, a new approach, pulsed-field ablation, appears promising. This is an in-depth summary of current technologies and techniques for the ablation of non-paroxysmal AF. We discuss the benefits, risks and implications in the treatment of patients with non-paroxysmal AF.

• Keywords
• atrial fibrillation, catheter ablation, pulmonary vein isolation, radiofrequency ablation,
• MeSH
• Electrophysiologic Techniques, Cardiac methods   MeSH
• Atrial Fibrillation * MeSH
• Catheter Ablation * methods   MeSH
• Humans MeSH
• Recurrence MeSH
• Pulmonary Veins * surgery   MeSH
• Treatment Outcome MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Review MeSH

BACKGROUND: Atrial fibrillation is common in patients with structural heart disease who are undergoing cardiac surgery. Surgical CryoMaze has been shown to be an effective treatment in several trials, but success rates have varied considerably, between 47-95%. The sequential hybrid approach, combining surgical CryoMaze followed by radiofrequency catheter ablation, can achieve high freedom from atrial arrhythmias. However, in patients with concomitant surgical atrial fibrillation treatment, data comparing the hybrid approach to CryoMaze alone are lacking. METHODS: The SurHyb study was designed as a prospective, open-label, multicentre randomized trial. Patients with non-paroxysmal atrial fibrillation who were scheduled for coronary artery bypass grafting or valve repair/replacement were randomized to either surgical CryoMaze alone or surgical CryoMaze followed by radiofrequency catheter ablation 3 months post-surgery. The primary outcome measure was arrhythmia-free survival without class I or III antiarrhythmic drugs, which has been evaluated using implantable cardiac monitors. CONCLUSIONS: This is the first randomized study that compares concomitant surgical CryoMaze alone with the staged hybrid surgical CryoMaze followed by catheter ablation, in patients with non-paroxysmal atrial fibrillation using rigorous rhythm monitoring. The results may contribute to the optimization of the treatment in patients undergoing concomitant CryoMaze for atrial fibrillation.

• Keywords
• Atrial fibrillation, Catheter ablation, Cryomaze, Hybrid treatment,
• MeSH
• Anti-Arrhythmia Agents therapeutic use   MeSH
• Atrial Fibrillation * surgery   drug therapy   MeSH
• Cardiac Surgical Procedures * methods   MeSH
• Catheter Ablation * methods   MeSH
• Humans MeSH
• Multicenter Studies as Topic MeSH
• Prospective Studies MeSH
• Randomized Controlled Trials as Topic MeSH
• Treatment Outcome MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Clinical Trial Protocol MeSH
• Names of Substances
• Anti-Arrhythmia Agents MeSH

• Keywords
• Ablation, Anticoagulation, Arrhythmia, Atrial fibrillation, Atrial flutter, Atrial tachycardia, Catheter ablation, Stroke, Surgical ablation,
• MeSH
• Atrial Fibrillation diagnosis   physiopathology   surgery   MeSH
• Catheter Ablation adverse effects   standards   MeSH
• Consensus MeSH
• Cryosurgery adverse effects   standards   MeSH
• Humans MeSH
• Risk Factors MeSH
• Cardiac Catheterization adverse effects   standards   MeSH
• Treatment Outcome MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Review MeSH
• Practice Guideline MeSH

PURPOSE: Hybrid ablation of atrial fibrillation (AF) is a promising treatment strategy for patients with non-paroxysmal AF, although, data regarding mid-term outcomes are limited. METHODS: Patients with persistent or long-standing persistent AF were enrolled. Initially, a thoracoscopic, right-sided, epicardial ablation was performed, with a goal of creating a box lesion on the posterior wall of the left atrium; a novel versapolar radiofrequency (RF) catheter was used. In patients enrolled later, occlusion of the left atrial appendage was also performed. An endocardial procedure was performed 2-4 months later, with the goal of confirming/completing the box lesion and ablating the ganglionated plexi and cavotricuspid isthmus. Efficacy was assessed using multiple 24-h and 1-week Holter monitoring. Analysis was performed to search for variables associated with procedure's failure. RESULTS: Forty-one patients (14 persistent and 27 long-standing persistent AF) were enrolled with a mean AF duration of 33.5 ± 33.1 months. Mean follow-up was 507.2 ± 201.1 days (180-731). At the last follow-up visit, 27(65%) patients were arrhythmia-free, without anti-arrhythmics or need for re-ablation. Additional 4 patients (9.8%) were in sinus rhythm (SR) following re-ablation of postprocedural peri-mitral flutter and 4 (9.8%) were in SR on anti-arrhythmics. Longer periods of preoperative AF were independently associated with worse arrhythmia-free survival (p = 0.015). Serious postoperative complications occurred in 3 (7.3%) patients; only 1 (2.4%) patient had clinical consequences after 6 months. CONCLUSIONS: Hybrid ablation of non-paroxysmal AF using a novel, versapolar RF device yields promising mid-term results. Better arrhythmia-free survival rates were found in AF patients with shorter AF duration.

• Keywords
• Atrial fibrillation, Hybrid ablation, Long-standing persistent, Persistent, Versapolar device,
• MeSH
• Equipment Safety MeSH
• Time Factors MeSH
• Chronic Disease MeSH
• Equipment Design MeSH
• Electrocardiography, Ambulatory methods   MeSH
• Electrocardiography methods   MeSH
• Atrial Fibrillation diagnostic imaging   surgery   MeSH
• Risk Assessment MeSH
• Catheter Ablation instrumentation   methods   MeSH
• Cohort Studies MeSH
• Middle Aged MeSH
• Humans MeSH
• Monitoring, Physiologic instrumentation   methods   MeSH
• Follow-Up Studies MeSH
• Recurrence MeSH
• Retrospective Studies MeSH
• Aged MeSH
• Severity of Illness Index MeSH
• Treatment Outcome MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH

• Keywords
• Ablation, Anticoagulation, Arrhythmia, Atrial fibrillation, Atrial flutter, Atrial tachycardia, Catheter ablation, Stroke, Surgical ablation,
• MeSH
• Ablation Techniques standards   MeSH
• Atrial Fibrillation surgery   MeSH
• Cardiology * MeSH
• Catheter Ablation standards   MeSH
• Consensus Development Conferences as Topic * MeSH
• Humans MeSH
• Heart Conduction System surgery   MeSH
• Societies, Medical * MeSH
• Check Tag
• Humans MeSH
• Publication type
• News MeSH

The midterm efficacy of hybrid ablation of atrial fibrillation (AF) reported in recent papers is about 70% in terms of sinus rhythm maintenance without antiarrhythmic drugs. Bearing in mind that the majority of patients enrolled are patients with persistent and long-standing persistent AF, the reported efficacies seem to be very good. Despite the high efficacies, safety remains a critical issue in hybrid, and especially thoracoscopic ablations. The frequency of complications during thoracoscopic ablations is more than 10% in the majority of reports. Most are short-term with no sequelae (such as pneumothorax or pneumonia); however, life-threatening complications have also been described, e.g., a sternotomy in response to a laceration of the left atrium (LA). One of the most serious ablation complications is stroke. The rate of strokes, which has been reported during or shortly after thoracoscopic ablation, seems to be higher than the rate reported after catheter ablation. This is especially true in papers describing thoracoscopic ablations that were not immediately followed by a catheter ablation. A possible explanation is differences in anticoagulation management during the two procedures. During catheter endocardial procedures, a standard anticoagulation protocol exists and is routinely applied; however, there is no such set of recommendations for anticoagulation during the thoracoscopic-phase of an ablation. It seems probable that, in many cases, no anticoagulation is used during thoracoscopic ablations. Moreover, whatever anticoagulation protocol is used during thoracoscopic ablations often goes unreported. A discussion about the best anticoagulation strategy during thoracoscopic ablation is urgently needed. In the future, standards of anticoagulation during thoracoscopic ablation should be clearly reported, just as they are now for catheter ablations.

• Keywords
• Hybrid ablation, anticoagulation, long-lasting persistent atrial fibrillation (AF), persistent atrial fibrillation (AF), stroke, thoracoscopic ablation,
• Publication type
• Comment MeSH
• Editorial MeSH

BACKGROUND: Atrial fibrillation is common in patients with structural heart disease who are undergoing cardiac surgery. Surgical CryoMaze has been shown to be an effective treatment in several trials, but success rates have varied considerably, between 47-95 %. The sequential hybrid approach, combining surgical CryoMaze followed by radiofrequency catheter ablation, can achieve high freedom from atrial arrhythmias, even when rigorous methods to detect arrhythmias after the procedure are used. However, data from randomized trials comparing hybrid ablations to surgical ablations alone are lacking. METHODS/DESIGN: The SurHyb study is a prospective, multicenter, randomized study. Patients with persistent or long-standing persistent atrial fibrillation will be randomized to either surgical CryoMaze alone or surgical CryoMaze followed by catheter ablation 3 months post-surgery. The primary outcome measure is arrhythmia-free survival without class I or III antiarrhythmic drugs, which will be evaluated using 7-day ECG Holter monitoring at 24 months. A total of 260 patients will be investigated from three medical centers in the Czech Republic to obtain the relevant information. DISCUSSION: This is the first randomized study that compares surgical CryoMaze alone with the staged hybrid surgical CryoMaze followed by catheter ablation in patients with persistent or long-standing persistent atrial fibrillation. These results will contribute to the optimization of the treatment for these patients. TRIAL REGISTRATION: Czech Clinical Trials Registry, cz-301020151253 . Registered on 30 October 2015.

• Keywords
• Atrial fibrillation, Catheter ablation, CryoMaze, Hybrid approach, Randomized controlled clinical trial, Surgical ablation,
• MeSH
• Anti-Arrhythmia Agents therapeutic use   MeSH
• Time Factors MeSH
• Electrocardiography, Ambulatory MeSH
• Atrial Fibrillation diagnosis   physiopathology   surgery   MeSH
• Catheter Ablation * adverse effects   MeSH
• Clinical Protocols MeSH
• Cryosurgery * adverse effects   MeSH
• Humans MeSH
• Disease-Free Survival MeSH
• Prospective Studies MeSH
• Recurrence MeSH
• Treatment Outcome MeSH
• Research Design MeSH
• Check Tag
• Humans MeSH
• Male MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH
• Research Support, Non-U.S. Gov't MeSH
• Randomized Controlled Trial MeSH
• Comparative Study MeSH
• Geographicals
• Czech Republic MeSH
• Names of Substances
• Anti-Arrhythmia Agents MeSH