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.