Hybrid Thoracoscopic‐Endocardial Versus Endocardial Catheter Ablation for Persistent Atrial Fibrillation: A Systematic Review and Meta‐Analysis

Background Hybrid ablation (HA) addresses the limitations of endocardial catheter ablation (CA) in patients with persistent, long‐standing atrial fibrillation (AF). This review compares hybrid thoracoscopic‐endocardial ablation with endocardial CA in this population to evaluate rhythm‐control outcomes and procedural safety. Methods Randomized controlled trials and observational studies comparing HA with CA in adults with non‐paroxysmal AF were identified through searches of PubMed, Embase, and Cochrane databases (November 2025). The review was registered with PROSPERO (CRD42024600526). Primary outcomes included freedom from AF, any atrial arrhythmia, use of antiarrhythmic drugs (AADs), arrhythmia recurrence, and repeat ablation. Results Eight studies (907 patients: 478 HA; 429 CA) were included. Compared to CA, HA did not significantly reduce AF (OR 2.38; 95% CI 0.66–8.65) or arrhythmia recurrence (OR 1.66; 95% CI 0.31–9.06). HA significantly reduced any atrial arrhythmia (OR 3.36; 95% CI 2.16–5.23) and AADs (OR 3.25; 95% CI 2.20–4.82) and repeat ablation rates (OR 0.28; 95% CI 0.09–0.90). HA increased risk of significant complications (OR 2.73; 95% CI 1.18–6.27) despite a significantly shorter fluoroscopy time. Heterogeneity reflected variations in lesion sets, epicardial energy modality, surgical access, timing, and comparator CA strategies. Recent randomized trials show comparable safety profiles for HA and CA when hybrid procedures are performed in experienced multidisciplinary programs. Conclusion HA offers better rhythm control than CA in persistent AF, although it involves greater procedural complexity. In appropriately selected patients and institutions with established hybrid expertise, HA is an effective rhythm‐control strategy that yields clinically significant benefits.