INTRODUCTION
Patients with long-standing persistent atrial fibrillation (LSPAF)
represent a major challenge for both cardiologist and cardiac
surgeons(1). Despite continuous improvements, catheter-based procedures
have shown poor outcomes and may need repeated transcatheter procedure
to achieve sinus rhythm(2). Surgical minimally invasive approach
combining a surgical epicardial and a transcatheter endocardial ablation
has emerged as alternative treatment, with encouraging results(3–5).
Electrical isolation of the left atrial posterior wall (’box lesion’)
represents the target of the epicardial approaches. Nevertheless, other
cardiac structures outside the posterior wall might play a role in the
atrial fibrillation (AF) genesis, i.e. the ligament of Marshall, the
left atrial appendage or the superior vena cava.
Bachmann’s bundle (BB) is a muscular structure comprising of
parallel-aligned myocardial strands, connecting the right and left
atrial wall. It represents the main pathway of inter-atrial conduction
and its disruption may result in various atrial tachyarrhythmias.
Surgical isolation of the BB does not require additional blunt
dissection since, during an epicardial approach, it is easily accessible
just beneath the descending aorta. BB may be involved in the
pathogenesis and sustaining of a number of unstable re-entrant circuits
and it has been hypothesized that its isolation could prevent induction
of stable AF(6–8).
Aim of this study was to explore the feasibility, effectiveness, and
safety of adding BB ablation to a predetermined right- and left atrial
lesion set, in the setting of a two-staged hybrid ablative approach as
first line strategy in LSPAF.