The convergent procedure involves a two-phase approach to ablating, or destroying, heart tissue that causes atrial fibrillation, or the misfiring of the heart muscle in the left upper chamber of the heart (left atrium).
In this procedure, performed robotically at Memorial Hermann, a heart surgeon first ablates the outer wall of the heart—known as epicardial ablation—to prevent electrical signals that trigger the heart muscle to contract erratically. Six to eight weeks later, an electrophysiologist—a physician who specializes in treating heart rhythm disorders—accesses the left atrium from inside the heart through a catheter and similarly ablates the inner wall of the atrium. This is known as endocardial ablation.
These two approaches, known together as the robotic convergent procedure, have been shown to successfully stop the misfiring, or arrythmia, in people with longstanding persistent atrial fibrillation (LSPAF) who have not seen relief of their AFib symptoms with antiarrhythmic medications or through other treatments.
Studies, including the landmark CONVERGE Clinical Trial published in November 2020, show that the hybrid convergent procedure reduced atrial fibrillation occurrences by more than 90% 18 months after the procedure. It also eliminated the need for newer or higher doses of antiarrhythmic medications.
Study authors consider this an effective treatment for LSPAF, compared with catheter ablation only. Because few adverse effects took place during the trial, researchers also consider it relatively safe.
Documented risks of the convergent procedure include pericardial effusion, or fluid retention in the sac surrounding the heart, bleeding and stroke. Careful postprocedure management, such as proper drain maintenance, anti-inflammatory medications and patient monitoring, has been shown to minimize these risks.
To reduce the risk of stroke, surgeons affiliated with Memorial Hermann clip the left atrial appendage while the patient is undergoing the robotic epicardial ablation in the operating room. The left atrial appendage has been associated with the development of blood clots that can break off during atrial fibrillation and travel to the brain, causing debilitating strokes. The clipping of this structure reduces or eliminates the need for implantable devices to minimize stroke risks.
The convergent procedure is performed in two distinct procedures conducted about eight weeks apart. Both require general anesthesia.
During the first procedure, known as an epicardial ablation, a cardiothoracic surgeon makes three or four small incisions in the chest. The surgical robot is then positioned over the body and surgical instrumentation, along with imaging and monitoring devices, are passed into the body through those incisions. The incisions also allow the arms of the robot, within the body, to function as the arms and hands of the surgeon. This minimally invasive approach reduces the risk of complications that can occur with an open procedure.
The surgeon operates the arms of the robot from a console within the operating room, using hand and foot controls, looking at the highly magnified structures of the heart with a 3D video camera placed inside the chest.
Through the robot’s arms, and with mapping technology monitored by an electrophysiologist in the room, radio waves are delivered to the back of the heart muscle near the upper left chamber, or atrium. These radio waves, also known as radiofrequency (RF) energy, create scars, or lesions, on the surface of the heart to disrupt misfiring electrical signals that can lead to atrial arrhythmias such as atrial fibrillation.
Patients generally stay in the hospital for up to two days following the first phase of the procedure and are closely monitored for any complications. Once they fully recover from this phase, usually six to eight weeks, the second phase of the treatment—endocardial ablation—can be performed by an electrophysiologist.
During the endocardial procedure, the electrophysiologist threads a catheter to the heart through a vein in the groin. Once inside the left atrium and guided by mapping technology to pinpoint the area of the heart responsible for misfiring, RF energy is used to destroy the heart tissue. These areas of destroyed tissue disrupt the electrical signals that cause atrial fibrillation.
Once this portion of the convergent procedure is completed, patients remain in the hospital for a few hours to prevent bleeding from the groin. Patients are followed at regular intervals after the procedure to monitor their heart rhythm and to determine whether medications are still needed.
At Memorial Hermann, affiliated heart surgeons use a surgical robot to perform the ablation of the outside wall of the left atrium. The use of the robot makes this surgery minimally invasive, as it doesn’t involve a large incision in the chest or accessing the heart through the sternum. The procedure requires only three small incisions that allow surgical instruments and imaging mechanisms to enter the body. The surgeon is seated at a console inside the operating room to perform the surgery. There is also no need for a cardiopulmonary bypass machine, which is routine in many heart surgeries, further reducing the risk of complications.
Memorial Hermann has invested in the robotic platform, along with advanced ablation and mapping technology, to shorten the procedure time and minimize risks from open heart surgery. Memorial Hermann’s affiliated heart surgeons and electrophysiologists collaborate on each convergent procedure and follow each patient’s recovery to deliver optimal care.
Memorial Hermann is one of only a few health systems in the United States that offers minimally invasive robotic cardiac surgery. In fact, less than 5% of cardiac surgeons have been trained to use the surgical robot to perform heart surgery. At Memorial Hermann, robotic heart surgery is used to treat various heart conditions.
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