Stepwise endo‐/epicardial catheter ablation for atrial fibrillation: The Mediterranea approach

Background Outcomes of catheter ablation (CA) among patients with nonparoxysmal atrial fibrillation (AF) are largely disappointing. Objective We sought to evaluate the feasibility, effectiveness, and safety of a single‐stage stepwise endo‐/epicardial approach in patients with persistent/longstanding‐persistent AF. Methods We enrolled 25 consecutive patients with symptomatic persistent ( n = 4) or longstanding‐persistent ( n = 21) AF and at least one prior endocardial procedure, who underwent CA using an endo‐/epicardial approach. Our anatomical stepwise protocol included multiple endocardial as well as epicardial (Bachmann's bundle [BB] and ligament of Marshall ablations) components, and entailed ablation of atrial tachycardias emerging during the procedure. The primary outcome was freedom from any AF/atrial tachycardia episode after a 3‐month blanking period. The secondary outcome was patients' symptom status during follow‐up. Results The stepwise endo‐/epicardial approach allowed sinus rhythm restoration in 72% of patients, either directly ( n = 6, 24%) or after AF organization into atrial tachycardia ( n = 12, 48%). BB's ablation was commonly implicated in arrhythmia termination. After a median follow‐up of 266 days (interquartile range, 96 days), survival free from AF/atrial tachycardia was 88%. Antiarrhythmic drugs could be discontinued in 22 patients (88%). As compared to baseline, more patients were asymptomatic at 9‐month follow‐up (0% vs. 56%, p = .02). Five patients (20%) developed mild medical complications, whereas one subject (4%) had severe kidney injury requiring dialysis. Conclusion A single‐stage endo‐/epicardial CA resulted in favorable rhythm and symptom outcomes in a cohort of patients with symptomatic persistent/longstanding‐persistent AF and one or more prior endocardial procedures. Epicardial ablation of BB was commonly implicated in procedural success.