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The aim of this study was to assess the safety and efficacy of a new subxiphoid hybrid epicardial-endocardial atrial fibrillation (AF) ablation and left atrial appendage (LAA) ligation approach for the treatment of persistent AF.Surgical hybrid ablation procedures have shown promise for maintaining sinus rhythm versus catheter ablation but are associated with increased periprocedural adverse events.Patients with symptomatic persistent AF (n = 33, mean age 64 ± 9 years, 25 men) who had antiarrhythmic drug therapy or prior catheter ablation was unsuccessful were referred for hybrid epicardial-endocardial AF ablation and LAA exclusion. LAA closure was confirmed by transesophageal echocardiographic Doppler flow and/or computed tomographic angiography 1 to 3 months post-ligation. The incidence of atrial tachycardia or AF recurrence, LAA closure, thromboembolic events, and post-operative complications were assessed.All 33 patients underwent successful LAA ligation with epicardial ablation of the posterior left atrial wall, as well as endocardial pulmonary vein isolation and cavotricuspid isthmus ablation. Freedom from atrial tachycardia or AF was 91% (20 of 22 patients) at 6 months, 90% (18 of 20 patients) at 12 months, 92% (11 of 12 patients) at 18 months, and 92% (11 of 12) at 24 months. There were no acute periprocedural complications (7 days). Thirty-day adverse events included 2 patients with pericardial effusion requiring pericardiocentesis and 1 incisional hernia repair. There were no long-term complications, strokes, or deaths. LAA ligation was complete in 27 of 33 subjects (82%), with 6 subjects having leaks of 5 mm.Subxiphoid hybrid epicardial-endocardial ablation with LAA ligation is feasible, safe, and effective. Future prospective studies are needed to validate these initial findings.

The greatest priority in treating atrial fibrillation (AF) is stroke prevention. There are now 3 main approaches to prevention: (1) oral anticoagulation (OAC), (2) eradication of AF, and (3) exclusion of the left atrial appendage (LAA) from the systemic circulation. The goal of this article is to review these approaches, with particular emphasis on nonpharmacologic methods and their role in light of current evidence. OAC is effective but is limited by major bleeding, physician and patient reluctance to use anticoagulants, and patient noncompliance. Eradication of AF with antiarrhythmic drugs has not been effective, and suppression with ablation has not yet been properly tested for stroke prevention. Finally, occlusion of the LAA is promising, but definitive evidence of efficacy for stroke prevention is lacking. Trials such as WATCHMAN LAA System for Embolic Protection in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the WATCHMAN LAA Closure Device in Patients With Atrial Fibrillation vs Long-Term Warfarin Therapy (PREVAIL) provide the best quality evidence for LAA device closure, with results suggesting noninferiority to OAC. Surgical trials have yet to show the efficacy of LAA occlusion for stroke prevention. This review highlights the evidence behind each of these approaches and concludes that to date OAC remains the standard for stroke prevention in AF. Future trials will need to address novel OAC therapy when comparing them with LAA exclusion, and large randomized trials will be required to ascertain indications for nonpharmacologic therapy in current practice.