Long-term outcomes for patients undergoing hybrid ablation for atrial fibrillation

Hybrid ablation (HA) for atrial fibrillation (AF) consists of a thoracoscopic epicardial ablation followed by an endocardial, catheter ablation. Several small randomized controlled trials have recently demonstrated the efficacy of this approach; however, the data are limited by modest sample sizes with limited follow-up. In this study we evaluate the long-term efficacy of HA in a large single-institution series over a 10-year period.

Patients with refractory AF underwent HA between the years of 2015 and 2025 at a single institution with a single surgeon. Epicardial ablation consisted of pulmonary vein isolation, isolation of the posterior left atrium, and left atrial appendage clip application. Patient medical records were reviewed for demographics, comorbidities, medications, recurrence of AF, operative reports, pathology reports, length of hospital stay, stroke, and death. Recurrence was defined as AF >30 seconds in duration beyond a 90-day blanking period on 24 hour or longer continuous monitoring. Patients were followed for up to 9 years.

In total, 304 patients were identified who underwent the first-stage epicardial ablation, 239 of whom also completed the second-stage endocardial ablation between the years of 2015 and 2025. At 1 year, 81% of patients were in normal sinus rhythm and 64% were also off all class I and class III antiarrhythmic drugs. At 5 years these rates were 66% and 47%, respectively. Eight patients (2.6%) required conversion to open maze, and 30-day mortality occurred in 1 patient (0.3%). In 199 patients (65% of cases) the epicardial ablation was performed through a left sided only thoracoscopic approach, which was associated with a mildly shorter hospital length of stay compared to bilateral thoracoscopic approach (3 days vs 4 days, P = .0038), lower rate of intensive care unit admission (9% vs 18% P = .038), and equivalent rates conversion to open maze and AF recurrence at 1 year. In total, 14 patients were incidentally found to have amyloid deposits in left atrial appendage specimens sent for pathology, 3 of these patients had a transthyretin amyloidosis subtype.

In this large single-institution study of hybrid ablation outcomes over a 10-year period, we demonstrate excellent short- and long-term freedom from AF with low rates of complication and conversion to open surgery. Left sided, unilateral thoracoscopic access was safe and benefitted patients' length of stay and rate of intensive care unit admission. It may be beneficial to routinely send left atrial appendage specimens at the time of epicardial ablation.