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Hybrid Epicardial and Endocardial Ablation of Persistent or Permanent Atrial Fibrillation: A New Approach for Difficult Cases


  • This work was supported by a 21C Frontier R&D Grant #SC3140.

  • Manuscript received 25 February 2007; Revised manuscript received 14 April 2007; Accepted for publication 2 May 2007.

Address for correspondence: Young-Hoon Kim, M.D., Ph.D., 126-1 Anam-5ga Seungbuk-ku, Seoul, Republic of Korea, 136-705. Fax: +82-2-927-1478; E-mail:


Background: Although percutaneous epicardial catheter ablation (PECA) has been used for the management of epicardial ventricular tachycardia, the use of PECA for atrial fibrillation (AF) has not yet been reported.

Objective: To evaluate the efficacy and feasibility of a hybrid PECA and endocardial ablation for AF.

Methods: We performed PECA for AF in five patients (48.6 ± 8.1 years old, all male, four redo ablation procedures of persistent AF with a risk of pulmonary vein (PV) stenosis, one de novo ablation of permanent [AF]) after an endocardial AF ablation guided by PV potentials and 3D mapping (NavX). Utilizing an open irrigation tip catheter, a left atrial (LA) linear ablation from the roof to the perimitral isthmus or localized ablation at the junction between the LA appendage and left-sided PVs or ligament of Marshall (LOM) was performed.

Results: PECA of AF was successful in all patients with an ablation time of <15 minutes. The left-sided PV potentials were eliminated by PECA in all patients. Bidirectional block of the perimitral line was achieved in two of two patients and a left inferior PV tachycardia with conduction block to the LA was observed during the ablation in the area of the LOM in one patient. A hemopericardium developed in one patient, but was controlled successfully. During 8.0 ± 6.3 months of follow-up, all patients have remained in sinus rhythm (four patients without antiarrhythmic drugs).

Conclusion: A hybrid PECA of AF is feasible and effective in patients with redo-AF ablation procedures and at risk for left-sided PV stenosis or who are resistant to endocardial linear ablation.