Published: December 26, 2025 | Updated: December 30, 2025
An active 60-year-old male with atrial fibrillation (A-fib) had been seen by Norton Heart & Vascular Institute cardiothoracic surgeon Steven M. Peterson, M.D., and after endocardial ablation was still symptomatic. His condition limited his ability to exercise and engage in his role as a soccer referee and long-distance runner.
Despite five direct current cardioversion treatments in one year, the patient remained symptomatic. He was referred to the Norton Heart & Vascular Institute Heart Rhythm Center and Kent E. Morris, M.D., MBA, for an ablation and oral amiodarone.
Kent E. Morris, M.D., MBA
Electrophysiologist
Norton Heart & Vascular Institute
Steven M. Peterson, M.D.
Cardiothoracic Surgeon
A two-stage hybrid ablation procedure with cardiothoracic surgery and electrophysiology was recommended for A-fib management. The two-step procedure is about a six-month process with two procedures about eight weeks apart, intended to decrease heart failure risk and heart failure-related symptoms, morbidity and mortality. It is indicated and Food and Drug Administration approved for persistent and long-standing persistent A-fib or indicated for paroxysmal A-fib if medical treatment failed or there is high risk of failure of treatment.
Stage 1, performed by a cardiothoracic surgeon, is an epicardial ablation (outside the heart like a surgical maze procedure) performed by subxiphoid incision. A device is used to create scar tissue intentionally to block erratic electrical signals. Left video-assisted thoracoscopy is used for the application of AtriClip, which is a left atrial appendage occlusion stroke-prevention device. The patient has a two- or three-day stay in the hospital. Pain-control steps include cryo nerve ablation, enhanced recovery after surgery protocol, gastrointestinal and pericarditis prophylaxis, glucose management and skilled therapy.
The patient has restrictions on lifting and driving for a couple of weeks and follows up with the cardiac surgery team in four weeks. Generally this is well tolerated, and patients are able to return to work in two to four weeks.
Stage 2 is an outpatient catheter procedure performed by the electrophysiology cardiology team about eight weeks after the first ablation. It’s done in the catheterization lab with a transesophageal echocardiogram (TEE) to check the left atrial appendage clip for a good seal. Then, based on an electrical map of the heart, any signals that remain after the first procedure are ablated, following a targeted course around the pulmonary veins. Since this is typically on an outpatient basis, it has less recovery/downtime so the patient can return to activity more quickly than inpatient procedures.
The patient followed up with electrophysiology four weeks after the procedure and again at three months. The patient stayed in normal rhythm, and the TEE showed the AtriClip was in good position. The patient was taken off anticoagulation medication. The patient is on no additional medications and is back to his activities, including running.