Minimally invasive thoracoscopic surgical ablation and hybrid ablation in AF patients: results from a single-arm systematic review and meta-analysis

Atrial fibrillation (AF) is the most frequent cardiac arrhythmia in adults, with presentations from asymptomatic to severe cardiovascular morbidities. Cardiac ablation treats patients resistant to antiarrhythmic drugs (AAD) using approaches such as bilateral surgical ablation, which permits targeting of superior vena cava lesions but entails longer procedures and higher complication risk, and hybrid ablation that combines epicardial and endocardial techniques. We performed a meta-analysis per PRISMA guidelines, including observational and interventional single-arm studies of patients undergoing bilateral surgical or hybrid ablation in single- and double-setting subgroups. Studies were selected by predefined criteria, and data were extracted independently by 12 investigators. Searches covered multiple databases up to March 29, 2025. Thirty-two studies with 1,871 patients were evaluated. Overall complication rates were 0.11 (95% CI: 0.08–0.14) for surgical ablation and 0.13 (95% CI: 0.095–0.17) for hybrid ablation, with no significant subgroup difference (p = 0.093). Arrhythmia-free rates were 0.81 (95% CI: 0.69–0.89) for surgical and 0.76 (95% CI: 0.70–0.85) for hybrid ablation (p = 0.305). Mean operative times were 160.9 min (95% CI: 135 − 186.9) for surgical and 192.65 min (95% CI: 109.3–275.9) for hybrid ablation (p = 0.069). Bleeding rates were 0.03 (95% CI: 0.02–0.04) and 0.049 (95% CI: 0.03–0.07), respectively (p = 0.06). Mortality, stroke, conversion to sternotomy, and hospital length of stay showed no significant differences. Surgical ablation yielded a slightly higher arrhythmia-free rate and fewer total complications, while hybrid ablation had shorter operative time; subgroup (single vs. double setting) differences were not significant.