eComment. The importance of intra-procedural end-points for the long-term success of hybrid ablation

We read with interest the manuscript by Budera et al. [1] regarding the 1-year clinical outcomes following a sequential-staged approach for hybrid ablation of non-paroxysmal atrial fibrillation. While the authors should be commended for their results, the manuscript raises several issues both in terms on electrophysiological findings and postoperative results. With respect to technical aspect of the surgical ablation, the authors repeated a combination of uni- and bipolar radiofrequency energy two to three times (with a total ablation time possibly around 6-8 minutes). It is imperative to remember that the cornerstone of this approach (i.e. epicardial ablation with a linear device encircling all pulmonary veins ‘en bloc’) is the possibility to create a continuous, single isolation line along the whole posterior aspect of the left atrium. Failure to do so could easily lead to an extremely arrhythmogenic substrate. A recent European trial [2] reported an average ablation time around 18 minutes but even up to 23-25 minutes in selected cases. Such difference may explain the different outcomes, not only in the early postoperative period but also at follow-up. Furthermore, the authors did not report whether an extensive epicardial fat removal was performed at the level of the interatrial groove, which allows for the elimination of the ganglionated plexi localized in such region, but also for a better positioning of the ablation probe (and ultimately improved energy penetration). Regarding the intraoperative validation of the surgical ablation, Budera et al. were able to achieve an exit block only in 80% of the patients. The authors did not clearly disclose whether a multi-electrode catheter was utilized on the pulmonary veins (to demonstrate local capture) with sensing in the coronary sinus. Similarly, the evaluation of entrance block (now recommended as Class I intervention) was not tested, despite it has been previously demonstrated that the achievement of a bi-directional block leads to higher rates of sinus rhythm restoration [3]. The incomplete surgical ablation could have contributed also to the development of atypical left-sided atrial flutter; in fact, the occurrence of peri-mitral flutter was 0% in previously published series with this technique [2,3]. A rigorous validation of the surgical ablation should always be advocated, especially in those instances where a more sophisticated intraoperative mapping is not available such as a sequential-staged hybrid ablation setting. Conflict of interest: none declared.

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