A Bayesian meta-analysis on recurrence of atrial arrhythmia between Hybrid AF ablation and endocardial AF ablation

Abstract Background The outcome of ablation in persistent atrial fibrillation (AF) has been modest despite adding linear ablation or substrate modification. Hybrid AF ablation consisting of surgical epicardial ablation concomitant or staged endocardial left atrial ablation being emerged as an alternative to. Comparative studies are characterised by limited sample size, diverse results and variations in lesions set. Objective This is the first meta-analysis of studies comparing the outcome of Hybrid ablation to endocardial ablation for persistent AF patients with Bayesian meta-regression analysis [PROSPERO ID CRD42024601042]. Methods A systematic literature search was performed to include both randomized and observational studies comparing Hybrid ablation to endocardial ablation for persistent AF. The selected studies underwent formal critical appraisal. Baseline and outcome data were extracted. Primary outcome was recurrence of atrial arrhythmia. Meta-regression analysis was performed for range of covariates. Secondary outcomes were procedural complications and hospital stay. Statistical analysis was performed in R platform using random effect model. Results 15 studies (4 RCT; 2 multi-centric; 3 Asian; 10 thoracoscopic; 7 staged hybrid) were selected for the meta-analysis including a total of 1671 patients of persistent and long-standing persistent AF[SD6] . The inclusion criteria of the patients as well as lesion sets in the surgical and endocardial ablation across the studies were diverse . The frequentist model showed significantly lower recurrence of atrial arrhythmia in the hybrid ablation group [log RR -0.27; 95%CI (-0.53, -0.02)] (Fig 1A), and the effect was maintained even after the Bayesian adjustment [log RR -0.29; 95%CI (-0.57, -0.03)] (Fig 1B) and the effect strengthened [log RR -0.36; 95%CI (-0.59, -0.14)] after adjusting for significant (p = 0.04) small study-bias (Fig 1C). In the meta-regression analysis none of the variables (viz. age, LA size, follow-up duration, lesions sets, LAA occlusion, previous AF ablations, and duration of AF, design of the study or even use of non-thoracoscopic approach) had any significant effect on the recurrence of atrial arrhythmia. Short-term complications were significantly higher [log RR 0.60; 95%CI (0.05, 1.14)] (Fig 2), and the duration of hospital stay was longer in the hybrid group [MD 3.54; 95%CI (1.62, 5.46) days] (Fig 2). Conclusions Hybrid AF ablation was found to be superior to catheter ablation even after Bayesian and small study-bias adjustments, however complications were more and hospital stays were longer implicating further need for cost-effectivity analysis.Figure 1 Figure 2