eComment. The importance of intra-procedural end-points for the long-term success of hybrid ablation
Bibliographic record
Abstract
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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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.012 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.002 | 0.002 |
| Scholarly communication | 0.002 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.023 | 0.020 |
| Insufficient payload (model declined to judge) | 0.006 | 0.006 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".