In the last 20 years, catheter ablation has produced significant advances in the treatment of atrial fibrillation (AF). Pulmonary veins (PVs) isolation, the cornerstone of AF treatment, is highly efficacious in paroxysmal patients. However, PVs isolation is not sufficient in the face of persistent and long-standing persistent AF. The potential for open heart surgical ablation to treat nonparoxysmal AF is well described but is typically performed as a component of another cardiac surgical procedure. Patients who do not require open heart surgery have limited nonparoxysmal AF management options. The absence of strategies to consistently and effectively address nonparoxysmal atrial fibrillation by nonpharmacological interventions represents a treatment gap. To close this gap, a “hybrid” approach with minimally invasive epicardial and endocardial ablation (“Convergent”) that combines the advantages of both techniques has garnered increasing acceptance in clinical practice in the last decade. The targets of this treatment strategy are two key drivers of AF: PVs and left atrial posterior wall (LAPW). The epicardial component seeks to debulk as much of the LAPW as can be accessed, principally limited by the oblique sinus. Posterior segments of the PV ostia/antra may also be reached and ablated in most cases. The endocardial component supplements the epicardial lesions around the pericardial reflections as well as any incompletely ablated LAPW areas, and addresses any remaining gaps between the PV and LAPW lesion sets (including anterior segments), ensuring PV electrical isolation. The endocardial component can also include a right cavotricuspid ablation line to prevent typical atrial flutter.
Patient selection (“first line approach” or after failure of anti-arrhythmic drugs or after failure of PVs isolation), mitigation of complications, long-term outcome, and the adjunctive value of left atrial appendage transthoracic epicardial exclusion are all topics requiring further discussion: this is the aim of this special issue of Reviews in Cardiovascular Medicine. We hope this discussion will provide our readers with new insights into the role of Convergent ablation in nonparoxysmal AF.
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