Borut Geršak, MD, PhD, Matevž Jan, MD The Annals of Thoracic Surgery

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Long-Term Success for the Convergent Atrial Fibrillation Procedure: 4-Year Outcomes Borut Geršak, MD, PhD, Matevž Jan, MD The Annals of Thoracic Surgery Volume 102, Issue 5, Pages 1550-1557 (November 2016) DOI: 10.1016/j.athoracsur.2016.04.018 Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Original convergent procedure lesion pattern. Pulmonary vein isolation, achieved with both epicardial lesions (blue) and endocardial lesions (red), is combined with a single posterior line connecting the left pulmonary vein (LPV) and right pulmonary vein. (IVC = inferior vena cava; LA = left atrium; LV = left ventricle; PA = pulmonary artery; RA = right atrium; SVC = superior vena cava.) The Annals of Thoracic Surgery 2016 102, 1550-1557DOI: (10.1016/j.athoracsur.2016.04.018) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Current, revised convergent procedure lesion pattern. Pulmonary vein isolation, achieved with both epicardial lesions (blue) and endocardial lesions (red), is combined with multiple, parallel, interconnecting lines that ablate a much larger surface area of the posterior left atrium. (IVC = inferior vena cava; LPV = left pulmonary vein; LV = left ventricle; PA = pulmonary artery; RA = right atrium; SVC = superior vena cava.) The Annals of Thoracic Surgery 2016 102, 1550-1557DOI: (10.1016/j.athoracsur.2016.04.018) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Anatomic map of left atrium in a patient who underwent the convergent procedure. At this point in the procedure, the epicardial ablation has already been performed. (A) Left anterior oblique view. (B) Posteroanterior view. Beige points represent areas in the antra of the pulmonary veins without endocardial voltage (actual necrosis after epicardial ablation). Red points represent areas with detectable endocardial voltage where endocardial ablation was performed. Necrosis after epicardial ablation is located mainly in the posterior, inferior, and inferoanterior part of the pulmonary vein antra. Closure of the antral circular line with endocardial ablation lesions isolated the ipsilateral veins. (LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.) The Annals of Thoracic Surgery 2016 102, 1550-1557DOI: (10.1016/j.athoracsur.2016.04.018) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Voltage map of the left atrium in a patient with previous convergent procedure and recurrence of atrial fibrillation. (A) Modified left anterior oblique view with mostly normal voltage (purple color) on the anterior wall and a small area of low voltage (yellow and red color) on the septum. (B) Posteroanterior view with large area of scar (gray color) on the posterior wall after previous epicardial ablation. A few strategically placed ablations (red dots) in the area of close to normal voltage on the antrum of the pulmonary veins caused reisolation of the superior veins. There was no reconduction in the inferior veins. (LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; PVP = pulmonary vein potentials; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.) The Annals of Thoracic Surgery 2016 102, 1550-1557DOI: (10.1016/j.athoracsur.2016.04.018) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions