Combined Epicardial and Endocardial Ablation for Atrial Fibrillation: Best Practices and Guide to Hybrid Convergent Procedures

The absence of strategies to consistently and effectively address non-paroxysmal atrial fibrillation (AF) by nonpharmacologic interventions has represented a longstanding treatment gap. A combined epicardial/endocardial ablation strategy, the hybrid Convergent procedure, was developed in response to this clinical need. A subxiphoid incision is used to access the pericardial space facilitating an epicardial ablation directed at isolation of the posterior wall of the left atrium. This is followed by an endocardial ablation to complete isolation of the pulmonary veins and for additional ablation as needed. Experience gained with the hybrid Convergent procedure during the last decade has led to the development and adoption of strategies to optimize the technique and mitigate risks. Additionally, a surgical and electrophysiology "team" approach including comprehensive training is believed critical to successfully develop the hybrid Convergent program. A recently completed randomized clinical trial indicated that this ablation strategy is superior to an endocardial only approach for patients with persistent AF. In this review, we propose and describe best practice guidelines for hybrid Convergent ablation based on a combination of published data, author consensus, and expert opinion. A summary of clinical outcomes, emerging evidence, and future perspectives are also discussed.