Hybrid versus endocardial ablation for persistent atrial fibrillation: a systematic review and Bayesian meta-analysis.

BACKGROUND

The outcomes of endocardial catheter ablation in persistent atrial fibrillation (PsAF) and long-standing PsAF (LSPsAF) remain modest. Hybrid convergent ablation for AF comprises surgical epicardial ablation with concomitant or staged endocardial catheter ablation. Comparative studies remain limited.

OBJECTIVES

To systematically assess and compare the efficacy and safety of hybrid ablation (HA) and endocardial ablation (EA) in PsAF and LSPsAF.

METHODS

A systematic review and meta-analysis of randomized and observational studies comparing HA and EA was performed, with Bayesian adjustment and covariate analysis. The primary outcome was atrial arrhythmia recurrence. Secondary outcomes included procedural-related complications and length of hospital stay.

RESULTS

Fifteen studies (including four randomized controlled trials) with 1671 patients (HA, 734; EA, 937) were analyzed. Study inclusion criteria and ablation lesion sets varied widely. Atrial arrhythmia recurrence irrespective of antiarrhythmic drug use was significantly lower in the HA group [relative risk (RR) 0.74 (95% confidence interval (CI) 0.59–0.94), I2 = 73%, P = 0.01]. This result was not different in Bayesian random-effects model [log RR −0.30 (95% CI −0.59, −0.04)]. On multivariate analysis, LSPsAF was the strongest independent predictor of arrhythmia recurrence. Complications were significantly higher in the HA group [log RR 1.03 (95% CI 0.68–1.37), I2 = 0%, P = 0.0001] as was length of stay [mean difference 3.22 days (95% CI 1.74–4.7 days), I2 = 97%, P < 0.0001].

CONCLUSIONS

Hybrid convergent ablation for AF results in lower atrial arrhythmia recurrence than endocardial catheter ablation, at the expense of higher acute complication rates and longer hospital stay.