Anesthetic Considerations for the Convergent Plus Procedure: A Hybrid Approach to the Treatment of Nonparoxysmal Atrial Fibrillation

One third of the population will develop atrial fibrillation in their lifetime and 12.1 million people in the United States are expected to be affected by 2030. A long-standing gap exists in traditional pharmacologic and nonpharmacologic treatments for persistent atrial fibrillation. An innovative, hybrid treatment, commonly referred to as the Convergent Procedure, combines surgical ablation of the posterior left atrium through a minimally invasive subxiphoid incision with traditional endocardial ablation techniques. When the procedure includes ligament of Marshall ligation and epicardial occlusion of the left atrial appendage using a video-assisted thoracoscopic approach, it is termed the Convergent 'Plus' Procedure. Evidence indicates that the procedure is twice as effective as endocardial ablation alone, reducing the need for atrial fibrillation medications by half. Consequently, demand for the procedure has surged, and anesthesia providers are now caring for patients in cardiac operating rooms and hybrid cardiology suites nationwide. Successful execution of the Convergent Plus Procedure demands close coordination among interdisciplinary teams, including surgery, cardiology, and anesthesiology. Anesthetic management is complex, requiring certified registered nurse anesthetists to understand procedural stages, ensure proper patient positioning, manage lung isolation, and be prepared for numerous complications such as hemodynamic instability, hemorrhage, and stroke.