Epicardial thoracoscopic ablation versus endocardial catheter ablation for management of atrial fibrillation: a systematic review and meta-analysis

OBJECTIVES: In the treatment of patients with atrial fibrillation (AF), the efficacy and safety of epicardial thoracoscopic ablation (TA) versus endocardial catheter ablation (CA) using radiofrequency energy remains unclear. This meta-analysis was performed to assess the efficacy and safety of each ablation technique using a pooled comparative analysis. METHODS: Studies comparing the efficacy and safety of TA and CA were identified by searching electronic databases. Those that reported patients' freedom from atrial arrhythmia and significant side effects were included. RESULTS: Three randomized controlled trials (RCTs) and two retrospective cohort studies with a total of 587 patients were included in the meta-analysis (273 patients underwent TA and 314 patients underwent CA). The proportion of patients who were free of atrial arrhythmia without antiarrhythmic drugs during 12 months of follow-up was significantly higher after TA than after CA in the RCTs P < 0.001; relative risk (RR), 1.77; 95% confidence interval (CI), 1.34-2.32 and in the retrospective cohort studies (P = 0.010; RR, 1.68; 95% CI, 1.12-2.51). The incidence of significant side effects during the post-procedural period was significantly higher in the TA group than in the CA group in both the RCT (P = 0.007; RR, 7.23; 95% CI, 1.71-30.49) and the retrospective cohort studies (P = 0.020; RR, 4.39; 95% CI, 1.33-14.46). CONCLUSIONS: Based on the available data, TA was found to be more effective than CA in achieving freedom from atrial arrhythmia; however, TA had a higher rate of immediate post-procedural complications than CA.