{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T06:17:04Z","timestamp":1791613024095,"version":"4.3.4"},"reference-count":33,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2024,3,8]],"date-time":"2024-03-08T00:00:00Z","timestamp":1709856000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Pulmonary vein isolation is currently considered to be the gold standard for ablating paroxysmal atrial fibrillation. However, its efficacy is limited in patients with persistent atrial fibrillation. The convergent procedure has emerged as a hybrid ablation. This study aims, for the first time in the literature, to introduce a hybrid approach that includes epicardial ablation with cutting-edge robotic technology and subsequent electrophysiological study to verify and an endocardial ablation to complete the ablation lines. Methods: We present 18 cases of robotic-assisted epicardial hybrid ablation performed between April and December 2023 on patients with long-standing persistent atrial fibrillation (mean age: 64 \u00b1 5 years; mean duration: 4 \u00b1 2 years). All of the procedures were performed at \u201cHumanitas Gavazzeni Hospital\u201d, Bergamo, Italy. Robot-assisted epicardial ablation performed using the \u201cEpi-Sense AtriCure\u201d device was guided by monitoring electrogram morphology and point-by-point impedance drop. This approach also included left atrial appendage occlusion and the disconnection of the ligament of Marshall. An electrophysiological study and endocardial ablation were planned three months after the procedure. Results: The procedure was successfully executed in all patients with no major complications and a mean operative time of 142 \u00b1 22 min. None of the cases required conversion to full sternotomy or minithoracotomy. The procedure was performed in all cases without extracorporeal circulation and on a beating heart. Fifteen patients (83%) were extubated in the operating room. The length of stay in the intensive care unit was less than 24 h. Acute restoration of sinus rhythm was achieved in 12 out of the 18 patients (67%); the median duration of their hospital stay was two days. In the electrophysiological study, seven pts had sinus rhythm, two had atrial fibrillation, and one patient developed atrial flutter at 3-month follow-up. Patients underwent transcatheter ablation to complete the lesion set and, at the time of discharge, were all in sinus rhythm. Conclusions: In our initial experience, surgical atrial fibrillation ablation consisting of a unilateral thoracoscopic technique facilitated by a robotic platform and continuous EGM monitoring has proven to be safe and feasible. For the electrophysiological study at 3 months, completing the gaps in the surgical ablation lines could improve the clinical results of the technique in terms of sinus rhythm stability. However, mid- and long-term follow-up is required to demonstrate this.<\/jats:p>","DOI":"10.3390\/jcm13061563","type":"journal-article","created":{"date-parts":[[2024,3,8]],"date-time":"2024-03-08T10:10:52Z","timestamp":1709892652000},"page":"1563","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":17,"title":["Robotic-Assisted Epicardial Hybrid Ablation and Left Appendage Closure in Persistent Atrial Fibrillation: First European Experience"],"prefix":"10.3390","volume":"13","author":[{"given":"Alfonso","family":"Agnino","sequence":"first","affiliation":[{"name":"Department of Cardiovascula Surgery, Division of Robotic and Mini-Invasive Cardiac Surgery, Humanitas Gavazzeni-Castelli, 24125 Bergamo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Giroletti","sequence":"additional","affiliation":[{"name":"Department of Cardiovascula Surgery, Division of Robotic and Mini-Invasive Cardiac Surgery, Humanitas Gavazzeni-Castelli, 24125 Bergamo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ascanio","family":"Graniero","sequence":"additional","affiliation":[{"name":"Department of Cardiovascula Surgery, Division of Robotic and Mini-Invasive Cardiac Surgery, Humanitas Gavazzeni-Castelli, 24125 Bergamo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6015-9844","authenticated-orcid":false,"given":"Piersilvio","family":"Gerometta","sequence":"additional","affiliation":[{"name":"Department of Cardiovascula Surgery, Division of Robotic and Mini-Invasive Cardiac Surgery, Humanitas Gavazzeni-Castelli, 24125 Bergamo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matteo","family":"Parrinello","sequence":"additional","affiliation":[{"name":"Department of Cardiac Anesthesia, Humanitas Gavazzeni-Castelli, 24125 Bergamo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni","family":"Albano","sequence":"additional","affiliation":[{"name":"Department of Cardiac Anesthesia, Humanitas Gavazzeni-Castelli, 24125 Bergamo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eduardo","family":"Celentano","sequence":"additional","affiliation":[{"name":"Cardiac Electrophysiology Complex Operational Unit, Humanitas Gavazzeni-Castelli, 24125 Bergamo, Italy"},{"name":"Cardiology Department, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ernesto","family":"Cristiano","sequence":"additional","affiliation":[{"name":"Cardiac Electrophysiology Complex Operational Unit, Humanitas Gavazzeni-Castelli, 24125 Bergamo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3519-770X","authenticated-orcid":false,"given":"Giuseppe","family":"Nasso","sequence":"additional","affiliation":[{"name":"Faculty of Health, Medicine and Life Sciences, Maastricht University, 6211 LK Maastricht, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0259-6691","authenticated-orcid":false,"given":"Natasja M. S.","family":"de Groot","sequence":"additional","affiliation":[{"name":"Cardiology Department, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,3,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"E1","DOI":"10.1093\/ejcts\/ezw313","article-title":"2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS","volume":"50","author":"Kirchhof","year":"2016","journal-title":"Eur. J. Cardio-Thoracic. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1016\/j.vph.2016.03.006","article-title":"Atrial fibrillation burden and atrial fibrillation type: Clinical significance and impact on the risk of stroke and decision making for long-term anticoagulation","volume":"83","author":"Boriani","year":"2016","journal-title":"Vascul. Pharmacol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2840","DOI":"10.1016\/j.jacc.2014.04.019","article-title":"Clinical classifications of atrial fibrillation poorly reflect its temporal persistence: Insights from 1195 patients continuously monitored with implantable devices","volume":"63","author":"Charitos","year":"2014","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"444","DOI":"10.1111\/ijcp.12326","article-title":"AF burden is important\u2014Fact or fiction?","volume":"68","author":"Boriani","year":"2014","journal-title":"Int. J. Clin. Pract."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1056\/NEJM199809033391003","article-title":"Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins","volume":"339","author":"Shah","year":"1998","journal-title":"N. Engl. J. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1016\/j.jtcvs.2004.08.042","article-title":"Surgical treatment of atrial fibrillation: Predictors of late recurrence","volume":"129","author":"Gaynor","year":"2005","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"E008128","DOI":"10.1161\/CIRCEP.119.008128","article-title":"Diagnosis-to-Ablation Time and Recurrence of Atrial Fibrillation Following Catheter Ablation: A Systematic Review and Meta-Analysis of Observational Studies","volume":"13","author":"Chew","year":"2020","journal-title":"Circ. Arrhythmia Electrophysiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.athoracsur.2005.06.046","article-title":"Innovative monolateral approach for closed-chest atrial fibrillation surgery","volume":"80","author":"Bisleri","year":"2005","journal-title":"Ann. Thorac. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"II191","DOI":"10.1161\/01.cir.0000089043.82199.2f","article-title":"Totally endoscopic atrial septal defect repair with robotic assistance","volume":"108","author":"Argenziano","year":"2003","journal-title":"Circulation"},{"key":"ref_10","first-page":"E38","article-title":"A completely endoscopic approach to microwave ablation for atrial fibrillation","volume":"6","author":"Saltman","year":"2003","journal-title":"Heart Surg. Forum"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1961","DOI":"10.1111\/jce.15594","article-title":"Staged hybrid totally thoracoscopic maze and catheter ablation for atrial fibrillation","volume":"33","author":"Churyla","year":"2022","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Marini, M., Pannone, L., Della Rocca, D.G., Branzoli, S., Bisignani, A., Mouram, S., Del Monte, A., Monaco, C., Gauthey, A., and Eltsov, I. (2022). Hybrid Ablation of Atrial Fibrillation: A Contemporary Overview. J. Cardiovasc. Dev. Dis., 9.","DOI":"10.3390\/jcdd9090302"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1186\/s13019-023-02189-2","article-title":"Mid term freedom from atrial fibrillation following hybrid ablation, a systematic review and meta-analysis","volume":"18","author":"Eranki","year":"2023","journal-title":"J. Cardiothorac. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"837","DOI":"10.1161\/CIRCULATIONAHA.113.005119","article-title":"Worldwide epidemiology of atrial fibrillation: A global burden of disease 2010 study","volume":"129","author":"Chugh","year":"2014","journal-title":"Circulation"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1142","DOI":"10.1016\/j.amjcard.2013.05.063","article-title":"Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population","volume":"112","author":"Colilla","year":"2013","journal-title":"Am. J. Cardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1541","DOI":"10.1016\/j.athoracsur.2015.07.006","article-title":"The ABLATE trial: Safety and efficacy of cox Maze-IV using a bipolar radiofrequency ablation system","volume":"100","author":"Philpott","year":"2015","journal-title":"Ann. Thorac. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"56","DOI":"10.14797\/VNDG5944","article-title":"Surgical Treatment of Atrial Fibrillation","volume":"17","author":"Wolf","year":"2021","journal-title":"Methodist. Debakey Cardiovasc. J."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"797","DOI":"10.1016\/j.jtcvs.2005.03.041","article-title":"Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation","volume":"130","author":"Wolf","year":"2005","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1016\/j.athoracsur.2007.08.014","article-title":"Video-Assisted Epicardial Ablation and Left Atrial Appendage Exclusion for Atrial Fibrillation: Extended Follow-Up","volume":"85","author":"Wudel","year":"2008","journal-title":"Ann. Thorac. Surg."},{"key":"ref_20","first-page":"3","article-title":"Robotic cardiac surgery: What the young surgeon should know","volume":"35","author":"Melly","year":"2020","journal-title":"Brazilian J. Cardiovasc. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"827515","DOI":"10.3389\/fcvm.2021.827515","article-title":"Robotic Cardiac Surgery in Europe: Status 2020","volume":"8","author":"Cerny","year":"2022","journal-title":"Front. Cardiovasc. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"88","DOI":"10.15420\/aer.2019.20","article-title":"The Convergent Atrial Fibrillation Ablation Procedure: Evolution of a Multidisciplinary Approach to Atrial Fibrillation Management","volume":"9","author":"Wats","year":"2020","journal-title":"Arrhythmia Electrophysiol. Rev."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1732","DOI":"10.1016\/j.hrthm.2010.05.040","article-title":"Effect of linear ablation on spectral components of atrial fibrillation","volume":"7","author":"Yokokawa","year":"2010","journal-title":"Heart Rhythm"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1111\/j.1540-8167.2009.01611.x","article-title":"Magnetic Resonance Imaging-Confirmed Ablative Debulking of the Left Atrial Posterior Wall and Septum for Treatment of Persistent Atrial Fibrillation: Rationale and Initial Experience","volume":"21","author":"Segerson","year":"2010","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1007\/s00395-010-0132-1","article-title":"Discrepant electrophysiological characteristics and calcium homeostasis of left atrial anterior and posterior myocytes","volume":"106","author":"Suenari","year":"2011","journal-title":"Basic Res. Cardiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1046\/j.1540-8167.2004.03487.x","article-title":"Embryonic conduction tissue: A spatial correlation with adult arrhythmogenic areas","volume":"15","author":"Jongbloed","year":"2004","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2296","DOI":"10.1001\/jama.2022.8831","article-title":"Effect of MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation on Atrial Arrhythmia Recurrence in Patients with Persistent Atrial Fibrillation: The DECAAF II Randomized Clinical Trial","volume":"327","author":"Marrouche","year":"2022","journal-title":"JAMA"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1016\/j.ahj.2020.02.016","article-title":"Convergence of Epicardial and Endocardial RF Ablation for the Treatment of Symptomatic Persistent AF (CONVERGE Trial): Rationale and design","volume":"224","author":"DeLurgio","year":"2020","journal-title":"Am. Heart J."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1016\/j.jacep.2015.04.006","article-title":"Left atrial appendage ligation and ablation for persistent atrial fibrillation: The LAALA-AF registry","volume":"1","author":"Lakkireddy","year":"2015","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1929","DOI":"10.1016\/j.jacc.2016.07.770","article-title":"Left Atrial Appendage Isolation in Patients with Longstanding Persistent AF Undergoing Catheter Ablation: BELIEF Trial","volume":"68","author":"Burkhardt","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"416","DOI":"10.1093\/icvts\/ivs136","article-title":"Epicardial left atrial appendage clip occlusion also provides the electrical isolation of the left atrial appendage","volume":"15","author":"Starck","year":"2012","journal-title":"Interact. Cardiovasc. Thorac. Surg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1013","DOI":"10.1016\/j.jacep.2022.12.011","article-title":"Hybrid Ablation Versus Repeated Catheter Ablation in Persistent Atrial Fibrillation: A Randomized Controlled Trial","volume":"9","author":"Vroomen","year":"2023","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1186\/s13019-022-02019-x","article-title":"Hybrid approach for long-standing persistent atrial fibrillation: Immediate versus staged treatment","volume":"17","author":"Nasso","year":"2022","journal-title":"J. Cardiothorac. Surg."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/6\/1563\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T14:11:04Z","timestamp":1760105464000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/6\/1563"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,3,8]]},"references-count":33,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2024,3]]}},"alternative-id":["jcm13061563"],"URL":"https:\/\/doi.org\/10.3390\/jcm13061563","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,3,8]]}}}