Convergent Procedure for Treatment of Advanced Atrial Fibrillation

Podcast Transcript

Announcer:
Welcome to Cleveland Clinic Cardiac Consult brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.
Dr. Oussama Wazni:
Hello and welcome to this podcast where we're going to discuss a new development at the Cleveland Clinic with the CONVERGE or Convergent procedure for treatment of advanced atrial fibrillation. It is my honor to have with me today, Dr. Ed Soltesz, who's the co-director of our surgical afib program, and also Dr. Tyler Taigen, who is the director of quality and co-section head of the afib program here at the Cleveland Clinic. Ed, let's start with you. Could you please describe for us the CONVERGE procedure and how it may help our patients with atrial fibrillation?
Dr. Ed Soltesz:
Sure, Oussama. The Convergent procedure is the best combination of both the surgical and the catheter-based ablation procedures that we have available. We started with surgical treatment of atrial fibrillation almost 30 years ago with the open surgical maze procedure. And that was the cut and sew procedures, so that was a full sternotomy on cardiopulmonary bypass, where the surgeon actually compartmentalized the left atrium. And then, of course, had its attendant consequences and complications.
But we move then to alternative energy sources and to minimally invasive procedures. And at the same time was your development in the EP world of catheter-based ablation, which was also very successful. The convergent procedure is a combination of these two. It's a hybrid approach, where as surgeons, we make a small subxiphoid incision, an incision just below the rib cage, and sneak underneath the sternum into the pericardial cavity.
Dr. Ed Soltesz:
And we're able to do a complete ablation on the posterior wall of the left atrium, utilizing a device that's a bipolar radio-frequency suction device. And at the same time of doing, we're able to protect the esophagus and monitor temperature, of course, of the esophagus during that time. We've added an additional part to this convergent procedure and we call it the convergent plus operation.
Dr. Ed Soltesz:
And that is we do a small left thoracoscopic placement of a left atrial appendage clip, and we can also do further ablation through those small incisions on the left side as needed.
Dr. Oussama Wazni:
I want to emphasize this last part. That's where we actually took some innovation and we decided to also give our patients the benefit of clipping the left atrial appendage, because a lot of our patients have to be on anticoagulants long-term. But this way then, we can avoid this in the future, especially as they get older or develop risk factors for bleeding. I think that's a very important develop.
Dr. Oussama Wazni:
Now, Tyler, Dr. Taigen, we had a very important development just now in Heart Rhythm 2020, where there was a big study that was presented on the Convergent procedure. Could you tell us more?
Dr. Tyler Taigen:
That's right. It was a large randomized control trial, 27 centers, that enrolled. A total of 150 patients from 2013 through 2018. They were randomized two to one, so a hundred patients to having both the converge surgical approach and right after that a catheter-based approach, and then 50 patients to just the catheter-based approach. They were followed for a year. And importantly, all of the patients were persistent afib. A lot of our trials have just looked at paroxysmal. These were all persistent.
Dr. Tyler Taigen:
And in fact, 40 percent were longstanding persistent, meaning that they had atrial fibrillation continuously for 12 months or more. That's quite a bit different than most of the other trials that we've done. Looking at the results, primary efficacy of freedom from atrial fibrillation, 67 percent in the surgical catheter arm were free of afib, which was defined as less than 30 seconds, no escalation of medicines, or no other catheter ablations or cardio versions versus 49 percent in the catheter ablation arm. Quite a bit different.
Dr. Oussama Wazni:
That's an impressive result right there. And then the other aspect of the convergent procedure is that while it proves that addressing the posterior wall is very important in these patients with advanced atrial fibrillation, the way the posterior wall is addressed also protects the esophagus. Because when we do it endocardial, there is a chance that the esophagus can be damaged with the convergent. That is very, very unlikely, because we're ablating out to in. Could you comment on that, Ed?
Dr. Ed Soltesz:
Oussama, that's an important concept. Because when we're going in surgically, we are actually pushing the heart and left atrium up as we're doing our ablation away from the esophagus. We're monitoring temperature as well, but we rarely ever see any movement in the esophageal temperature during the convergent procedure. When you're doing an endocardial ablation, you're pushing from inside out. And of course, the esophagus is behind some areas. Again, I think the opportunity here really is to take the best of both worlds.
Dr. Ed Soltesz:
We take the opportunities that you have for endocardial ablation catheter-based approaches and what we can do surgically and address areas optimally surgically where you may not be able to catheter-base and you can do the same for us.
Dr. Oussama Wazni:
I think this is a very important development because in these patients with advanced atrial fibrillation with very large atrium, also the posterior wall thickness can be hypertrophic. It can be a lot thicker than what we can ablate through and through endocardially. And I think we're going to have great results in those patients. Just quickly also, could you address what we can expect in terms of recovery after the convergent? How many days would they spend in the hospital and the quality in the hospital?
Dr. Ed Soltesz:
The operation is about a four hour operation, and the patient is intubated for the surgery. We do not, of course, use cardiopulmonary bypass. We use a lot of local anesthetic, both for the left chest small incision, as well as the subxiphoid incision. But patients are routinely extubated at the end of the surgery. They just go to the short stay unit overnight. They have one chest tube. We've been using just one chest tube that enters into the pericardial cavity, then snakes out into the left chest.
Dr. Ed Soltesz:
We remove that small silastic drain the following morning, and usually they're able to be discharged on postoperative day three.
Dr. Oussama Wazni:
That's great. And then Tyler, what do we do after that?
Dr. Tyler Taigen:
Well, in the trial, we did these together. I think one important part of the overall management here is a lot of the evidence that we have in our EP world speaks just to isolating the pulmonary veins. If there's one thing that this trial I think highlights, it's that that's not enough in these persistent patients. And as you've said, you get the energy going away from the esophagus, where unfortunately we have it going towards the esophagus. The trial was not set up for us to ablate the posterior wall.
Dr. Tyler Taigen:
Sometimes we try and do that, but obviously it's limited technically. I think in our management of these patients, the key here and one of the other messages from this trial is it's going to require a team approach. This is going to require that we work together, and then we have these centers that can really tackle this kind of patient. But different than before, these are folks we can get in a rhythm and can expect good outcomes from.
Dr. Tyler Taigen:
And I think too often in the past, we've thought, you're in afib for a year, there's not a whole lot we can do. I think this changes that.
Dr. Oussama Wazni:
That's very good. All right. I think this was great. It's a great opportunity to treat even more patients and help even more patients who have this problem of longstanding persistent atrial fibrillation or advanced atrial fibrillation. And I think it's going to make a big difference, with the added benefit of also reducing the risk of stroke by left atrial appendage clip and also avoiding taking all anticoagulants in the long-term. Thank you both very much.
Announcer:
Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts or listen at clevelandclinic.org/cardiacconsultpodcast.