The Convergent Hybrid Ablation procedure has been gaining acceptance as an effective treatment option for long-standing persistent atrial fibrillation (AFib) since the CONVERGE trial data published in 2020 demonstrated a 78% improvement compared to endocardial catheter ablation alone. Recently, AdventHealth Daytona Beach cardiothoracic surgeon Patrick Mangonon, MD, became the first in Florida and one of the first in the country to perform the Convergent procedure robotically in an effort to further improve patient outcomes. This parallels the hospital’s growing experience and offering of general and specialized robotic surgical procedures.
A two-stage treatment designed to eliminate triggers of AFib, Convergent Hybrid Ablation begins with a left atrial epicardial (outer cardiac surface) ablation performed by a cardiothoracic surgeon. This is followed by a secondary, catheter-based endocardial (inner cardiac surface) ablation performed by a cardiology subspecialist, an electrophysiologist, a few weeks after the initial surgical procedure. Applying techniques used for robotic lung surgery, Dr. Mangonon began performing the left atrial epicardial ablation portion of the procedure using the DaVinci Xi surgical robot in late 2023 and has now completed more than 50 cases at AdventHealth Daytona Beach.
“I started performing the traditional Convergent procedure in 2022 but felt like the ablation of the left atrium was not as thorough as it could be due to anatomic limitations,” explains Dr. Mangonon. “I have since applied the same patient positioning and robotic instruments I use to perform routine lung surgery to help overcome these challenges and achieve a better overall outcome for patients suffering from AFib.”
Challenges with Treating Long-standing Persistent Atrial Fibrillation
The most common type of heart arrhythmia, AFib impacts approximately 12.1 million people in the U.S. It is a progressive disease that increases the risk of stroke, heart failure and other cardiac complications. When AFib lasts longer than one year without stopping, it is classified as long-standing persistent, and about 45% of people with AFib suffer from this advanced form of the condition. It is characterized by changes to structural components within the left atrium.
“There is a progressive mortality risk for those with untreated, long-standing AFib,” comments Dr. Mangonon.
Medical management in the form of anticoagulants and modifying risk factors is typically the first line of treatment for AFib. When the condition remains persistent, it may require additional intervention. Performed by an electrophysiologist, pulmonary vein isolation (PVI) is a minimally invasive procedure often used to treat AFib. A type of endocardial ablation, it uses radiofrequency, cryoenergy or electroporation to eliminate triggers of AFib in the left atrium.
“While frequently effective for treating patients with paroxysmal or mild forms of atrial fibrillation lasting less than seven days, PVI alone may not be enough to treat those with more advanced forms of the disease,” shares AdventHealth Daytona Beach cardiac electrophysiologist Marvin Lu, MD. “The addition of ablation of the posterior wall endocardially has mixed results and runs the risk of damaging the esophagus. A lot of studies have shown that as atrial fibrillation progresses, complex electrical and structural changes in the left atrium contribute additional triggers outside of the pulmonary veins alone, and a significant percentage of them are coming from the posterior wall. The Hybrid Ablation procedure was developed to provide a more extensive and durable isolation of the posterior wall while minimizing the risk of injury to the surrounding extracardiac tissue.”
Enhancing the Convergent Hybrid Ablation Procedure Through a Robotic Approach
The surgical portion of the traditional Convergent procedure involves accessing the heart by making a small, vertical incision in the subxiphoid, an area between the chest and abdomen. Then an Epi-Sense ablation catheter is manually delivered into the cavity and applied in a sequential manner to the outer surface of the left atrium.
“I found that thorough ablation was difficult to achieve using the traditional subxiphoid approach,” explains Dr. Mangonon. “By incorporating complete right lateral decubitus positioning and using the robotic platform, I can obtain superior visualization and exposure of the left atrium to perform a more thorough left atrial epicardial ablation with five smaller incisions. This helps to decrease pain, bleeding and infection while also shortening a patient’s hospital stay and speeding up their return to function. The robotic approach also allows me to exclude the left atrial appendage, further adding to the success rate in treating patients with long-standing persistent AFib.”
Dr. Lu often works collaboratively with Dr. Mangonon, performing the secondary endocardial portion of the Convergent Hybrid Ablation procedure, and has noticed advantages of the robotic approach.
“As physicians, we continually seek new techniques to increase our success rates, and I am an advocate for more extensive and comprehensive ablation,” says Dr. Lu. “The epicardial lesions Dr. Mangonon achieves through the robotic approach cover more surface area compared to the traditional subxiphoid approach, rendering most of the left atrium electrically inactive. This lessens the amount of endocardial ablation I must perform, shortening overall treatment time. I am excited about what we are seeing so far, and we are hopeful it will ultimately lead to better overall patient outcomes.”
Identifying Candidates for Hybrid Ablation
Dr. Mangonon and Dr. Lu emphasize that surgical treatment for AFib is not for everyone. Specific criteria for the Convergent Hybrid Ablation procedure include the following:
- More advanced (long-standing persistent) AFib
- Enlarged left atrium
- Scarred left atrial posterior wall
- Previously failed endocardial catheter ablation, especially if pulmonary veins were previously isolated
- Comorbid conditions like heart failure
“The higher the patient’s risk, the more aggressive we want to be in our treatment approach,” comments Dr. Lu.
Dr. Mangonon adds, “Any patient may be a candidate for robotic-assisted Convergent Hybrid Ablation. I trust my electrophysiology colleagues, and we select patients for the combined procedure in a collaborative manner.”
Striving to Continually Improve Outcomes for Patients with AFib
Looking ahead, the AdventHealth Daytona Beach team hopes to work with other centers across the country who are also performing robotic-assisted Convergent Hybrid Ablation procedures to develop a registry of cases and to share best practices. Dr. Mangonon also aims to train other surgeons on the robotic approach.
“We’re excited to pioneer this innovation and remain committed to working collaboratively to reduce the burden and progression of AFib for all those who suffer from it,” says Dr. Mangonon.
