Safety of hybrid epicardial–endocardial ablation in patients with persistent atrial fibrillation and heart failure with reduced left ventricular ejection fraction
O Ahmed, E J Behr, A Momin, R A KabaAbstract
Introduction
Atrial fibrillation (AF) ablation carries a Class I guideline recommendation in heart failure when the arrhythmia contributes to ventricular dysfunction. However, patients with significantly impaired left ventricular ejection fraction (LVEF) have been underrepresented in hybrid ablation trials, due to perceived procedural risk. As a result, the safety profile of hybrid epicardial–endocardial ablation in patients with reduced LVEF remains uncertain. We evaluated the procedural safety of Convergent hybrid ablation in this high-risk population.
Methods
Prospective single-centre study of consecutive patients with non-paroxysmal AF and LVEF <50% undergoing Convergent hybrid ablation. Patients with prior AF ablation or concomitant procedures were excluded. The primary endpoint was procedural safety, defined as major complications (requiring intervention or prolonging hospital admission) or minor complications (requiring monitoring or oral therapy) occurring during either the epicardial (Stage 1) or endocardial (Stage 2) component. Secondary endpoints included length of stay and complications through 12-month follow-up.
Results
Fifty patients were included (80% male; mean age 67.2±7.3 years; mean LVEF 36.6±7.6%). AF was persistent in 62% and long-standing persistent in 38%. Median AF duration was 13.5 [7–39] months. The cohort reflected advanced symptomatic heart failure (median NYHA III [II–III]; NT-proBNP 1308 [598–2105] pg/mL). All patients completed both procedural stages. The median length of stay was 1 day for each stage. Major complications occurred in 5 patients (10%): 4 after Stage 1 (8%) and 1 after Stage 2 (2%). No patient required emergency surgical intervention or prolonged critical care admission. Stage 1 events comprised transient ischaemic stroke with complete neurological recovery, pericardial effusion requiring readmission, wound infection requiring intravenous antibiotics, and incisional hernia requiring surgical repair. The single Stage 2 major complication was pulmonary oedema requiring intravenous diuresis. Minor complications occurred in 8 patients (16%) and were limited to access- or incision-related events managed conservatively. There was no procedural cardiovascular mortality.
Conclusion
In patients with symptomatic heart failure and reduced LVEF, Convergent hybrid ablation was associated with acceptable procedural safety, short hospital stays, and no cardiovascular mortality. These prospective data provide contemporary safety evidence in a population historically underrepresented in hybrid ablation studies and support consideration of this strategy in carefully selected patients with impaired ventricular functionHybridComplicationsReducedEF