Efficacy of Hybrid Therapy in the Form of Right Atrial Ablation and Adjunctive Therapy in Refractory Atrial Fibrillation in Symptomatic Patients

Symptomatic atrial fibrillation is often treated with antiarrhythmic drugs. Responsiveness is poor and adverse effects common. Nonpharmacologic treatments consisting of the Maze procedure and catheter-based pulmonary vein isolation are highly successful but invasive with complications. Right atrial ablation is relatively simple in comparison. Success ranges between 20% and 80%. Some studies have shown improved response when combined with antiarrhythmic drugs (AADs). We performed a review of available literature to determine the efficacy of hybrid therapy in the form of right atrial ablation, AAD with cardioversion, and pacing in reducing atrial fibrillation burden. All human studies studying efficacy of right atrial ablation and postablation AAD therapy in refractory atrial fibrillation were considered. The primary outcome was reduction of atrial fibrillation burden. The secondary outcome was significant adverse events. We searched Medline, EMBASE, CINAHL, and Cochrane databases. Data collection, analysis, and selection of studies were done independently by two review authors. We included six studies with variable numbers of participants and outcomes. We defined success of hybrid therapy as reduced burden of atrial fibrillation. Total subjects studied was 189, 26% female and 74% male. Average age was 58 years. Left atrial diameter was less than 5 cm and mean ejection fraction was 64%. Mean atrial fibrillation duration was 3.35 years. Most patients had failed at least two AADs. Hybrid therapy was successful in 82% patients. All forms of hybrid therapy consisting of right atrial ablation and AAD therapy seem to be reasonably effective in relief of symptoms from refractory atrial fibrillation with minimal side effects; however, much larger randomized trials need to be performed before a significant superiority of any one may be established.