Hybrid ablation for persistent atrial fibrillation: a narrative review.

BACKGROUND AND OBJECTIVE: Treatment for atrial fibrillation (AF) has evolved significantly, with pulmonary vein isolation (PVI) becoming an established treatment. However, the outcomes following catheter ablation for persistent AF remain unsatisfactory. Hybrid catheter-surgical ablation has emerged as a therapeutic approach for persistent AF, combining the strengths of both interventions. The purpose of this narrative review is to comprehensively examine the current state of knowledge regarding hybrid ablation for AF.

METHODS: A thorough PubMed search using the terms "hybrid ablation", "atrial fibrillation", "catheter ablation", and "guideline on cardiology" within the timeframe of 1980 to 2024 resulted in 138,969 articles. Consensus on the selected articles was reached through a series of structured meetings and discussions.

KEY CONTENT AND FINDINGS: PVI has demonstrated higher sinus rhythm maintenance rates, especially for paroxysmal AF. However, the efficacy is not as high for persistent AF. Additional ablation strategies, such as linear ablation, complex fractionated atrial electrogram ablation, low voltage zone ablation as well as posterior wall isolation, lack consistent evidence of effectiveness. Hybrid ablation, involving collaboration between cardiac surgeons and electrophysiologists, presents a promising alternative for hard-to-treat AF. Recent studies report favorable outcomes of hybrid ablation, with atrial arrhythmia-free rates ranging from 53.5% to 76%, surpassing those of catheter ablation alone, which might result from better lesion durability or intervention for non-PV foci and left atrial appendage excision or closure during hybrid ablation. The rate of complications associated with hybrid ablation is higher than catheter ablation alone.

CONCLUSIONS: While favorable outcomes of hybrid ablation for persistent AF have been reported, it is not recommended for all AF patients due to its invasiveness compared to catheter ablation. Additionally, some patients with persistent AF maintain sinus rhythm with catheter ablation alone. More clinical data are needed to determine which patients are suitable candidates for hybrid ablation.