Hybrid Ablation for Patients with Persistent and Long-Standing Persistent Atrial Fibrillation

Atrial fibrillation (AF) is the most commonly encountered arrhythmia, with a rapidly growing prevalence and significant cost to the global healthcare system. Left untreated, AF progresses over time from paroxysmal AF to persistent AF (perAF) and long-standing persistent AF (LS-perAF). AF is associated with significant mortality and morbidity by increasing the risk of developing cardiomyopathy, heart failure, dementia, stroke and systemic embolization. Endocardial catheter ablation (CA) targeting pulmonary vein isolation (PVI) alone is the most commonly employed treatment strategy for patients undergoing invasive treatment for all forms of AF. Despite technological improvements such as pulsed field ablation (PFA), procedural success rates in preventing AF recurrences in patients with perAF and LS-perAF remain suboptimal. A lack of lesion transmurality gives rise to epicardial–endocardial dissociation, which may contribute to AF recurrences. Hybrid ablation (HA) combines epicardial surgical ablation with endocardial CA. HA leads to greater freedom from AF in advanced AF compared to CA, and while existing data support the safety of HA, HA inherently is more invasive, requires a multidisciplinary approach, and has a 5–7.8% risk of major adverse events. HA is reasonable in patients with symptomatic, drug-refractory perAF or LS-perAF. Future directions include evaluating the role of novel operative technologies in HA.