Critical Role of the Posterior Left Atrium in the Perpetuation of Persistent Atrial Fibrillation and the Hybrid Ablation Approach for Persistent Atrial Fibrillation Management: A Single-center Outcomes Study.

Atrial fibrillation (AF) is the most common heart rhythm disorder and a growing major public health burden. AF ablation is considered to be the preferred rhythm control strategy for symptomatic drug-refractory paroxysmal and persistent AF (PRAF). To date, the long-term ablation success rates of pulmonary vein isolation (PVI) for PRAF and longstanding PRAF (LS-PRAF) have not paralleled those of paroxysmal AF. Additional concomitant ablation strategies such as linear ablation lesions in the left and right atria; autonomic ganglionic plexi ablation; ablation directed by complex fractionated atrial electrograms; ablation of nonpulmonary vein (PV) triggers; radiofrequency ablation of the vein of Marshall; and, most recently, focal impulse and rotor ablation/modulation have shown modest improvement in terms of efficacy, but no reproducible outcomes. Here, we describe the critical role of the posterior left atrium (LA) and PV region in the development and progression of PRAF and LS-PRAF. We discuss the results of single-center outcomes data for convergent or hybrid AF ablation of the posterior LA and PV region (endocardial PVI + minimally invasive epicardial posterior LA ablation). This epicardial ablation approach, combined with endocardial ablation, is an option for patients with PRAF and LS-PRAF. More definitive clinical trials are needed.