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Stepwise Endo-/Epicardial Catheter Ablation for Atrial Fibrillation: the Mediterranea Approach
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  • Giuseppe De Martino,
  • Paolo Compagnucci,
  • Carmine Mancusi,
  • Enrico Vassallo,
  • Claudia Calvanese,
  • Giuseppe Della Ratta,
  • Mariateresa Librera,
  • Marco Franciulli,
  • Luigi Marino,
  • Antonio Dello Russo,
  • Michela Casella
Giuseppe De Martino
Mediterranea Hospital, Naples
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Paolo Compagnucci
Department of Biomedical Sciences and Public Health, University Hospital "Umberto I-Lancisi-Salesi", Marche Polytechnic University
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Carmine Mancusi
Clinica Mediterranea
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Enrico Vassallo
Mediterranea Hospital, Naples
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Claudia Calvanese
Mediterranea Hospital, Naples
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Giuseppe Della Ratta
Mediterranea Hospital, Naples
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Mariateresa Librera
Mediterranea Hospital, Naples
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Marco Franciulli
Mediterranea Hospital, Naples
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Luigi Marino
Mediterranea Hospital, Naples
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Antonio Dello Russo
University Hospital “Ospedali Riuniti” and Marche Polytechnic University, Ancona
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Michela Casella
University Hospital “Ospedali Riuniti” and Marche Polytechnic University, Ancona
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Abstract

Background: Outcomes of catheter ablation (CA) among patients with non-paroxysmal 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=0.02). 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.

Peer review status:ACCEPTED

08 Feb 2021Submitted to Journal of Cardiovascular Electrophysiology
08 Feb 2021Submission Checks Completed
08 Feb 2021Assigned to Editor
10 Feb 2021Reviewer(s) Assigned
24 Feb 2021Review(s) Completed, Editorial Evaluation Pending
26 Feb 2021Editorial Decision: Revise Minor
25 Apr 20211st Revision Received
28 Apr 2021Submission Checks Completed
28 Apr 2021Assigned to Editor
28 Apr 2021Reviewer(s) Assigned
09 Jun 2021Review(s) Completed, Editorial Evaluation Pending
10 Jun 2021Editorial Decision: Accept