Hybrid epicardial and endocardial ablation versus endocardial ablation in patients with persistent and longstanding persistent atrial fibrillation: an updated systematic review and meta-analysis

Mazetto, Roberto; Bulhoes, Elisio; Antunes, Vanio do Livramento Junior; Defante, Maria Luiza Rodrigues; Garcez, Luanna; Barbosa, Lucas Federal; Queiroz, Ivo; Mendes, Beatriz X; Bastos, Eduarda; Silva, Catarina; Coelho, Anderson; Guerreiro, Isabel; Couceiro, Katia; Bueno, Bruno; Guida, Camila; Macedo, Harthur Moreira; Romeiro, Pedro

BACKGROUND:

Some studies suggest a potential benefit of hybrid ablation for patients with persistent and long-standing persistent atrial fibrillation (AF), but its efficacy and safety remain debated.

OBJECTIVE:

We conducted a systematic review and meta-analysis to compare the efficacy and safety of hybrid ablation and catheter ablation in patients with persistent AF and long-standing persistent AF.

METHODS:

We searched PubMed, Embase and Cochrane Central. Outcomes were the composite endpoints of freedom from atrial arrhythmias, major adverse events, total procedural time, and fluoroscopy time. Statistical analysis was performed using the R program (version 4.3.2). Heterogeneity was assessed with I2 statistics.

RESULTS:

We included 961 patients from 7 studies. Of those, 4 were RCTs and 3 were observational studies with propensity score matched cohorts. A total of 446 (46.41%) patients received hybrid ablation and 515 (53.59%) received only endocardial. Among the patients included in the study, 674 (70.14%) had persistent AF, and 287 (29.86%) had LSPAF. Moreover, the average atrial diameter was 4.43 cm, and the average duration since AF diagnosis was 3.06 years. Additionally, the average age of the patients was 61.7, and the number of male patients included was 911 (94.80%). The median follow-up ranged from 12 to 43.9 months. Compared to catheter ablation, hybrid ablation was associated with a higher odds of freedom from atrial arrhythmias off antiarrhythmic drugs (OR 3.25; 95% CI 2.08-5.06; p<0.001; I2 = 85%; Figure 1A), and freedom from AF (OR 3.51; 95% CI 1.07 - 11.48; P=0.038; I2=84%; Figure 1B). There were no differences in major adverse events (p=0.98; Figure 1C), total procedure time (p=0.05; Figure 2A), or fluoroscopy time (p=0.85; Figure 2C) between hybrid ablation and catheter ablation.

CONCLUSION:

This meta-analysis shows hybrid ablation increases the likelihood of maintaining freedom from atrial arrhythmias in patients with persistent and long-standing persistent AF, compared to catheter ablation, without compromising safety.