Hybrid versus endocardial ablation for persistent atrial fibrillation: a systematic review and Bayesian meta-analysis

BACKGROUND: The outcomes of endocardial catheter ablation in persistent atrial fibrillation (PsAF) and long-standing PsAF (LSPsAF) remain modest. Hybrid convergent ablation for AF comprises surgical epicardial ablation with concomitant or staged endocardial catheter ablation. Comparative studies remain limited. OBJECTIVES: To systematically assess and compare the efficacy and safety of hybrid ablation (HA) and endocardial ablation (EA) in PsAF and LSPsAF. METHODS: A systematic review and meta-analysis of randomized and observational studies comparing HA and EA was performed, with Bayesian adjustment and covariate analysis. The primary outcome was atrial arrhythmia recurrence. Secondary outcomes included procedural-related complications and length of hospital stay. RESULTS: Fifteen studies (including four randomized controlled trials) with 1671 patients (HA, 734; EA, 937) were analyzed. Study inclusion criteria and ablation lesion sets varied widely. Atrial arrhythmia recurrence irrespective of antiarrhythmic drug use was significantly lower in the HA group [relative risk (RR) 0.74 (95% confidence interval (CI) 0.59–0.94), I2 = 73%, P = 0.01]. This result was not different in Bayesian random-effects model [log RR −0.30 (95% CI −0.59, −0.04)]. On multivariate analysis, LSPsAF was the strongest independent predictor of arrhythmia recurrence. Complications were significantly higher in the HA group [log RR 1.03 (95% CI 0.68–1.37), I2 = 0%, P = 0.0001] as was length of stay [mean difference 3.22 days (95% CI 1.74–4.7 days), I2 = 97%, P < 0.0001]. CONCLUSIONS: Hybrid convergent ablation for AF results in lower atrial arrhythmia recurrence than endocardial catheter ablation, at the expense of higher acute complication rates and longer hospital stay.