Co-Author(s):
karl Crossen, MD
Jaswinder Gill, MD
Christopher Blauth, MD
Saumil Oza, MD
Anthony Magnano, MD
Mark Mostovych, MD
Michael Halkos, MD
Sreedhar Billakanty, MD
Steve Duff, MD
Christopher Stees, MD
Syed Ahsan, MD
John Yap, MD
Eric Espinal, MD
Otto Constantini, MD
David Gilligan, MD
Bruce Hook, MD
Tyler Taigen, MD
David Tschopp, MD
Faraz Kerendi, MD
Christian Shults, MD
Manish Shah, MD
David Pederson, MD
Anil Rajendra, MD
Jose Osorio, MD
Jonathan Silver, MD
Hugh Calkins, MD
Emory St Joseph’s
1364 Clifton Rd, Atlanta, GA
Introduction | Objectives: Long-standing persistent AF (LSPAF) is characterized by electroanatomical changes to left atrial substrate and clinical success with endocardial only ablation is limited. The CONVERGE multi-center randomized controlled trial demonstrated superior effectiveness of combined epicardial-endocardial (hybrid Convergent, HC) ablation to endocardial only catheter ablation (CA) for symptomatic, drug refractory, advanced AF treatment. A sub-analysis was conducted to compare the outcomes specifically in LSPAF.
Methods: In CONVERGE trial, a total of 153 adult symptomatic drug refractory patients were randomized to HC (N=102; 38 LSPAF) or CA (N=51; 27 LSPAF). Primary effectiveness was freedom from atrial arrhythmia through 12 months absent new/increased dose of previously failed anti-arrhythmic drugs (AADs). Secondary endpoints included freedom from AF, AF burden reduction, 18-month effectiveness (by 7-day Holter), and quality-of-life (QoL). Primary safety was major adverse event rate through 30-days post procedure.
Results: Baseline demographics in the LSPAF subgroup were similar in HC and CA arms - mean BMI (33 Vs 35), mean LA size (4.5 Vs 4.3 cm), cardioversion within 12 months (53% Vs 59%), mean AF duration (6.0 Vs 5.9 years). Mean ablation time in HC was 217 minutes (endocardial = 140 min, epicardial = 77min) and 181 minutes in CA. As a result of epicardial ablation, on an average 41 minutes of less endocardial ablation was required in HC arm.  Freedom from atrial arrhythmia was significantly higher in HC compared to the CA. The QoL and AF symptoms, as assessed by SF-36 and AFSS questionnaires at baseline and 12 months post-ablation, significantly improved in HC arm. No deaths or fatal events were reported in either arm. Three patients (7.8%) in HC and none in CA had primary safety events.
Conclusions: LSPAF subgroup analysis from the CONVERGE trial showed significant improvements in freedom from atrial arrhythmias and AF burden reduction with hybrid Convergent ablation compared to endocardial ablation only, with quality-of-life benefits. These are important findings as LSPAF patients currently have limited effective treatment options.