Hybrid Atrial Fibrillation Ablation

Treatment of atrial fibrillation (AF) has evolved significantly during the last 3 decades. Successful surgical AF ablation was developed by the pioneering work of Dr James Cox in 1987 resulting in the development of the Coxmaze (CM) procedure.1 Further experience and incorporation of ablation technology allowed subsequent modifications to increase efficacy and decrease morbidity, resulting in the latest iteration—the CM IV.2 Despite the excellent results of open SA of AF, its widespread use has been limited by its morbidity, especially for standalone surgical procedures. Ablation lines from alternate energy sources to replace many of the surgical incisions in the cut and sew maze led to a thoracoscopic, minimally invasive, off-pump beating heart approach.1 Minimally invasive thoracoscopic surgery may improve on the results of AF catheter ablation but may not be as effective as open surgery because of limitations in creating transmural lesions in roof and floor of the left atrial posterior wall in some patients.3 In 1998, the observation by Haïssaguerre et al2 that the pulmonary veins (PVs) serve as common sources of AF triggers in patients with paroxysmal AF paved the way for catheter AF ablation (CA) using radiofrequency energy. Although CA is associated with relatively low morbidity, it has been characterized by higher AF recurrence rates, especially in persistent and long-standing persistent AF.4 Because thoracoscopic SA and CA interventions may lead to incomplete isolation of the PVs and the posterior wall of left atrium, a hybrid option combining these 2 techniques was developed. The so-called hybrid strategies proposed to increase procedural success. In fact, single-center studies have demonstrated that catheter ablation may be effective in completing some of the lines created by the thoracoscopicbased SA procedure.5 Hybrid AF ablations in various centers have been variable in terms of surgical approach (thorascopic versus pericardioscopic), lesion sets applied by surgeon and electrophysiologist, timing of the staged procedures, type of energy used, exclusion of left atrial appendage (LAA), and the rigor and length of patient follow-up (Table 1). Despite the presence of observational data supporting the safety and efficacy of this approach, lack of prospective trials and the remaining unanswered questions temper its widespread use. This article will review the evidence behind hybrid AF ablation and provide a rationale for the US Food and Drug Administration–sponsored prospective multicenter trials to provide more meaningful data on the safety and efficacy of hybrid approaches to AF ablation.