eComment. Genuine hybrid or convergent treatment of atrial fibrillation. What should we choose?

Treatment for persistent atrial fibrillation (AF) includes different strategies for surgical and interventional procedures; nevertheless there are still no unified guidelines. The subject is associated with many controversies from anamnesis to follow-up. Thus, every clinic selects its own way. In this article the authors describe their experience with a “two-stage” hybrid treatment of AF. The results are very optimistic, statistics are provided, but the report still leaves more questions than answers [1]. First of all there is the selected strategy: two steps in treatment can be precluded by lack of funding, major complications or the absence of a hybrid OR. Although every patient requires an individual approach, there are more advantages in a one-step technique such as exact confirmation of transmurality of ablation lines and absence of endo-epicardial gaps. In addition, it reduces time of fluoroscopy and total procedure time.

The second question is follow-up. It is recognized that even 7-day Holter monitoring cannot provide objective information about sinus rhythm maintenance over the entire post-procedural period. Despite the popularity of this diagnostic method, continuous monitoring with an implanted loop recorder is preferred [2]. It is associated with a large number of asymptomatic paroxysmal events, especially in patients with non-paroxysmal AF. This condition may lead to inappropriate cancellation of anti-arrhythmic therapy and oral anticoagulant therapy and the return of AF or stroke as a consequence.

As previously mentioned, the results are optimistic. The data provided by the authors is in line with earlier reports on these methods with a mean total percentage of 90% of patients in sinus rhythm at 1-year follow-up [3]. The main problem is that the proper treatment of all forms of AF gives approximately 90-95% of success in the first year which progressively declines in subsequent years in patients with non-paroxysmal AF. Unfortunately there are still no big trials on the efficacy of hybrid treatment in long-term follow-up in order to confirm or refute this experience. Yet the two-step strategy brings one undeniable advantage. Inflammatory processes in ablation points become less with time. It allows the definition of boundaries of non-isolated substrate and target points. In conclusion, we recognize some benefits of a two-stage hybrid approach as one of the treatment modalities, but a definitive äsolution should take into account data from multicentre randomized trials.

Conflict of interest: none declared