Long-term outcomes of one-stop unilateral thoracoscopic hybrid ablation for persistent atrial fibrillation after failed catheter ablation

BACKGROUND: Hybrid ablation is a treatment option for persistent (PsAF) or long-standing persistent atrial fibrillation (LS-PsAF) after failed catheter ablation (CA), but long-term outcomes (> 5 years) and predictors of recurrence after hybrid ablation in this population have not been well characterized in prior studies. METHODS: We retrospectively analyzed 44 consecutive patients with symptomatic PsAF or LS-PsAF who underwent one-stop unilateral thoracoscopic hybrid ablation with left atrial appendage (LAA) management between May 2015 and April 2021. The procedure consisted of same-day epicardial and endocardial ablation. Primary endpoint was defined as recurrence of atrial arrhythmias ≥ 30 s after the 3-month blanking period, regardless of antiarrhythmic drug (AAD) use. Given the limited sample size and number of events, multivariable Cox regression was performed as an exploratory analysis. RESULTS: Patients (77.3% male; mean age 59.6 ± 8.3 years) had median AF duration of 8.0 years; 97.7% had prior failed CA (mean 1.4 ± 0.7 procedures). At discharge, 93.2% were in sinus rhythm, with no in-hospital mortality or stroke. Over median 5.2-year follow-up, freedom from arrhythmias at 1, 3, and 5 years was 68.2%, 52.3%, and 50.0%, respectively. Recurrence occurred in 22 patients (50.0%), with 63.6% of recurrences within the first year. On exploratory multivariable Cox regression analysis, left atrial (LA) diameter (HR 1.073, 95% CI: 1.001-1.151, P = 0.047) showed a potential association with recurrence. LAA pathology revealed myocardial hypertrophy (84.1%), inflammation (65.9%), and occult thrombus was identified in 10.0% of LAA specimens (4/40). No thromboembolic events occurred during follow-up. CONCLUSIONS: One-stop hybrid ablation with routine LAA management was associated with acceptable safety and rhythm control in half of patients with PsAF/LS-PsAF at 5 years within this exploratory cohort. These long-term data suggest hybrid ablation is a viable strategy in this challenging population. Although routine LAA resection/clipping yielded promising histological findings, definitive clinical benefits could not be confirmed within this single-arm cohort. Given the exploratory nature of the analysis and limited sample size, these findings require validation in larger prospective multicenter studies.