Table 4.

Evolution of hybrid ablation

First author, references (year)	Cases/participants	Age, years	Follow-up, years (unless otherwise indicated)	Study type	Key findings/messages
Wolf et al. [46]	27	57.2 ± 14.9	173.6  days	Single center: A new, minimally invasive, video-assisted thoracoscopic surgical (VATS) technique for AF ablation described	Perioperative mortality: 0% Hospital stay: 3.3 ± 1.0 days Late mortality: 0% Reintervention: 0% AF-free at 3 months: (21/23) 91.3% AF-free at 3 months off AADs: 65.3%
Edgerton et al. [47]	52	60.3	6 and 12 months via 24-h Holter monitor, 14-day event recorder or pacemaker interrogation	Single center: Thoracoscopic RF pulmonary vein isolation, ablation of GPs, and excision or stapling of LAA in 88%	Maintenance of sinus rhythm: 86.3% at 6 months and 80.8% at 12 months 81.4% (35/43) were not receiving AADs at 6 months and 89.2% (33/37) at 12 months
Krul et al. [52]	31 Paroxysmal AF = 16 Persistent AF = 13 Longstanding persistent AF = 2	57 ± 7 years	1 year	Single center: Thoracoscopic PVI in all patients ALAL for persistent and longstanding persistent AF Extensive periprocedural electrophysiological testing during procedure	At 1 year, 19 of 22 patients (86%) had no recurrent atrial tachyarrhythmias off AADs Three patients required a sternotomy because of uncontrolled bleeding There was 1 hemothorax, 1 pneumothorax, and 2 developed pneumonia treated with antibiotics
Mahapatra et al. [53]	15 patients with persistent or longstanding AF underwent sequential hybrid ablation 30 patients with persistent or longstanding AF underwent catheter ablation	Sequential:59.5 ± 2.4 Catheter only: 59.2 ± 1.5	Mean 20.7 ± 4.5 months	Comparison between patients that underwent sequential surgical epicardial-catheter endocardial ablation for persistent or longstanding persistent AF versus 30 who were treated only with catheter ablation All failed at least 1 prior catheter ablation	13/15 (86.7%) sequential patients versus 16/30 (53.3%) catheter-alone patients, were free of any atrial arrhythmia and off of AAD (p = 0.04). On AAD, 14/15 (93.3%) sequential patients were free of any atrial arrhythmia recurrence, compared to 17/30 (56.7%) catheter-alone patients (p = 0.01)
Pison et al. [54]	26 total 15 paroxysmal AF 10 persistent AF 1 longstanding persistent AF	56.8 ± 8.4	470 ± 154 days	Single center simultaneous combined thoracoscopic surgical and transvenous CA of paroxysmal and persistent AF	Over 1/3 of all patients had 1 or more previous catheter ablations Overall single-procedure success rate of 83% at 1 year
Je et al. [56]	1877 total patients Minimally invasive endocardial Cox-maze 145 Minimally invasive epicardial surgical ablation 1382 Minimally invasive hybrid surgical ablation 350	59.1	15.1 ± 10.3 Range 6–55 months	Systematic Review of 37 studies	At 1 year, rates of sinus rhythm restoration were 93, 80, and 70%, and sinus restoration without anti-arrhythmic medications were 87, 72, and 71%, for Cox-maze, epicardial and hybrid procedures, respectively The minimally invasive Cox-maze procedure with CPB support also had important safety advantages in conversion to sternotomy and major bleeding
Al-Jazairi et al. [64]	50 total 5 paroxysmal, 34 persistent 11 longstanding persistent	57 ± 9	Efficacy assessed with 12-lead EKG and 72-h Holter monitoring after 3, 6, and 12 months	Single center, single-stage hybrid (thoracoscopic surgical and transvenous CA) AF ablation	At 1-year follow-up, 76% of patients maintained sinus rhythm off antiarrhythmic drugs Patients with paroxysmal AF had the greatest success, longstanding persistent AF patients had the poorest (significantly lower) results Complications occurred in 7 patients: Bleeding requiring thoracotomy (2); Permanent phrenic nerve injury (2); Pericardial and pleural effusions requiring drainage (1); Pleural effusion requiring drainage (1); Permanent pacing needed due to sinus node dysfunction (1)
Haywood et al. [65]	175 total 9 did not undergo endocardial ablation 166 (95%) underwent staged hybrid ablation	62.2 ± 8.5	Median 18 months	Multicenter experience (four European centers) with staged hybrid ablation for persistent and longstanding persistent AF	Endocardial procedure performed ≥ 8 weeks post-surgery After (median) 18 months follow-up 56% were AF-free of AADs At last clinic follow-up, 132/175 (75.4%) were in sinus rhythm ± AADs Complications of the surgical stage of ablation occurred in 35/175 (20%). Complications of the second stage occurred in 4/166 (2.4%)*
DeLurgio et al. [67]	153 total randomized 2:1 to hybrid or endocardial catheter ablation Results from 12 months available in 149/153 (97.4%)	Hybrid: 63.7 ± 9.6 Endocardial catheter ablation: 65.1 ± 6.7	Twenty-four–hour Holter monitoring at 6 and 12 months 7-day monitor at 18 months Phone follow-up at years 2–5	Multicenter, randomized controlled trial comparing hybrid ablation to catheter ablation in patients with a left atrial size ≤ 6.0 cm and drug-resistant persistent and longstanding (42%) persistent AF	Hybrid convergent ablation had superior efficacy: AF freedom, absent new or increased dosage of previously failed class I/III AADs of 67.7% versus 50.0% (P = 0.036); AF freedom, off AADs, of 53.5% versus 32.0% (P = 0.0128) Major adverse events in the hybrid arm within 7 days: stroke (1), excessive bleeding (1), and excessive bleeding with late pericardial effusion (1) Major adverse events in the hybrid arm within 8–30 days: pericardial effusions (3), one phrenic nerve injury (1), and transient ischemic attack (1) Major adverse events were not reported in the catheter ablation arm
Ellenbogen et al. [72]	90 total 48% had failed catheter ablation Persistent AF present in 83.3% Longstanding persistent AF present in 16.7%	63.4 ± 7.74	1 year 24-h rhythm monitoring and ECG performed 6 and 12 months post catheter ablation	Multicenter (17 sites) trial of staged hybrid ablation	Catheter ablation was performed 91–121 days after epicardial procedure Primary effectiveness (freedom from atrial tachyarrhythmias [> 30 s] absent new/increased dose of previously failed AAD) was 70.6% (p = 0.0232); freedom from AF was 78.8% (p = 0.0002) Adverse events occurred in 6 patients and were equally distributed between the 2 procedural arms

^*Specific complications are enumerated in the text

AADs antiarrhythmic drugs; AF atrial fibrillation; ALAL additional left atrial lines; BPs ganglionic plexi; CA catheter ablation; CM centimeters; ECG electrocardiogram; LAA left atrial appendage; VATS video-assisted Thoracoscopic