Title:

Hybrid epicardial–endocardial ablation versus catheter ablation for non-paroxysmal atrial fibrillation: a systematic review and meta-analysis

Background:

While catheter ablation (CA) is effective for paroxysmal atrial fibrillation (AF), long-term success is limited in non-paroxysmal or long-standing persistent AF. This group often experiences recurrent arrhythmias despite antiarrhythmics and repeat ablations, impairing quality of life and increasing healthcare utilization. Hybrid epicardial–endocardial ablation (HA) combines surgical and catheter techniques, enabling the creation of durable lesions and the isolation of the posterior wall for improved rhythm control. Recent randomized controlled trials (RCTs) have shown promising results; however, existing systematic reviews are outdated, and therefore an updated review is needed to clarify efficacy and safety, as well as guide practice.

Methods:

The review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was registered on PROSPERO. Multiple databases and trial registries were searched using pre-defined terms. Eligible studies were RCTs and observational studies of adults with non-paroxysmal or long–lasting persistent AF comparing HA with CA. Two reviewers independently screened and extracted data. The primary endpoint was maintenance of sinus rhythm without the use of antiarrhythmics. Secondary endpoints included major complications, quality of life, repeat ablation, and rhythm outcomes at 24 months or more.

Results:

Five RCTs compared CA with HA in non-paroxysmal AF. Across all studies, HA consistently achieved higher arrhythmia-free survival at 12- 24 months (65-76% versus 32-43%; pooled benefit approximately 30% (p<0.001), including off antiarrhythmics (57-72% versus 28-41%). Both procedures had similar safety profiles, with comparable complication rates (8-11% versus 6-10%), no procedural mortality, and infrequent serious adverse effects such as tamponade and stroke. Lastly, HA also required fewer repeat procedures, such as cardioversion (12-16% vs. 24-29%) and repeat ablation (5-8% vs. 34-37%), compared to CA.

Conclusion:

In patients with non-paroxysmal AF, HA provides superior arrhythmia-free outcomes compared to CA, while maintaining a comparable safety profile.