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

Abstract 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, comprising 4 RCTs and 3 observational studies with propensity score-matched cohorts. A total of 446 (46.41%) patients received hybrid ablation, while 515 (53.59%) underwent endocardial ablation alone. Among the included patients, 674 (70.14%) had persistent AF, and 287 (29.86%) had long-standing persistent AF (LSPAF). The mean atrial diameter was 4.43 cm, and the average duration since AF diagnosis was 3.06 years. The mean patient age was 61.7 years, with 911 (94.80%) male patients. Median follow-up ranged from 12 to 43.9 months. Hybrid ablation was associated with no statistically significant difference in freedom from atrial arrhythmias (OR 2.92; 95% CI 0.99-8.58; p=0.051; I² = 87%; Figure 1A), while showing higher odds of freedom from atrial arrhythmias off antiarrhythmic drugs (OR 3.25; 95% CI 2.08-5.06; p<0.001; I² = 19%; Figure 1B). There was also no statistically significant difference in freedom from AF (OR 3.98; 95% CI 0.93-17.08; p=0.063; I² = 86%; Figure 1C) or in major adverse events (MAE) between groups (OR 0.99; 95% CI 0.32-3.04; p=0.986; I² = 42%; Figure 1D). Conclusion This meta-analysis indicates that hybrid ablation is associated with a higher likelihood of maintaining freedom from atrial arrhythmias off antiarrhythmic drugs in patients with persistent and long-standing persistent AF compared to catheter ablation. However, there was no statistically significant difference in overall freedom from atrial arrhythmias or freedom from AF. Additionally, hybrid ablation did not result in a higher incidence of major adverse events, indicating comparable safety to catheter ablation.