The safety and efficacy of hybrid ablation for the treatment of atrial fibrillation: A meta-analysis

January The safety and efficacy of hybrid ablation for the treatment of atrial fibrillation: A meta- analysis Yun-Qiu Jiang 0 1 Ying Tian 0 1 Li-Jun Zeng 0 1 Shu-Nan He 1 Zhi-Tao Zheng 1 Liang Shi 0 1 Yan- Jiang Wang 0 1 Yu-Xing Wang 0 1 Xian-Dong Yin 0 1 Xiao-Qing Liu 0 1 Xin-Chun Yang 0 1 Xing- Peng Liu 0 1 0 Cardiac Arrhythmias Section, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University , Beijing , China , 2 Department of Cardiology, Beijing Lu-He Hospital, Capital Medical University , Beijing , China 1 Editor: Katriina Aalto-Setala, University of Tampere , FINLAND Hybrid ablation, an emerging therapy that combines surgical intervention and catheter ablation, has become a viable option for the treatment of persistent atrial fibrillation. In this analysis, we aimed to evaluate the safety and efficacy of hybrid ablation, as well as compare the outcomes of one-step and staged approaches. - Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: Funded by National Natural Science Foundation of China (81370293, 81470023), author Y.T. URL: http://www.nsfc.gov.cn/. Capital Health Science Development Special Project (2016-1-2034), author X.L. URL:http://www.bjhbkj. com. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Methods Results We conducted a search in major online databases and selected the studies that met the inclusion criteria. The primary endpoint was defined as no episode of atrial fibrillation or atrial tachycardia lasting longer than 30 seconds without administration of antiarrhythmic drugs. Sixteen studies including 785 patients (paroxysmal atrial fibrillation, n = 83; persistent atrial fibrillation, n = 214; long-standing persistent atrial fibrillation, n = 488) were selected. Average history of atrial fibrillation was (5.0±1.6) years. The pooled proportion of patients who were arrhythmia-free at the primary endpoint was 73% (95% CI, 64%±81%, Cochran's Q, P<0.001; I2 = 81%). The pooled rate of severe short-term complications was 4% (95% CI, 2%±7%, Cochran's Q, P = 0.01; I2 = 51%). The success rate after one-step procedures (69%) was lower than that after staged procedures (78%). The staged approach could ultimately prove to be safer, although complication rates were relatively low for both approaches (2% and 5%, respectively). Conclusions Hybrid ablation is an effective and generally safe procedure. The current data suggest that staged hybrid ablation could be the optimal approach, as it is associated with a higher Competing interests: The authors have declared that no competing interests exist. success rate and a seemingly lower complication rate. Additional randomized controlled trials are necessary to confirm these results. Introduction Atrial fibrillation (AF) is the most common type of arrhythmia reported in clinical practice. As this condition is associated with an increased risk of major complications, such as thrombosis and stroke, finding optimal therapies for AF has long been a topic of interest among clinicians. Although the Cox Maze III procedure has been considered the gold standard for the surgical treatment of AF since 1991, [ 1 ] it has not been used extensively due to its complexity and invasive character. Pulmonary vein isolation (PVI), the standard catheter ablation procedure for paroxysmal AF (PrAF), has success rates exceeding 70% and acceptable complication rates [ 2 ]. However, neither epicardial ablation nor endocardial ablation alone can achieve a satisfactory result in patients with long-standing persistent AF (LSPsAF), making these patients prone to multiple repeat procedures and complications related to excessive atrial ablation. In recent years, surgeons have combined minimally invasive thoracoscopic surgery and percutaneous catheter ablation, creating a new procedure known as hybrid ablation, in an attempt to improve success rates and curb complication rates. A few systematic reviews have summarized the existing literature, focusing on aspects such as strategies for patient selection, periprocedural anticoagulation regimens, and ablation techniques [ 3,4 ]. However, the efficacy and safety of the hybrid ablation procedure have not been sufficiently studied. Factors that can influence the success rates and the incidence of perioperative complications are yet to be determined. To this end, we performed a pooled analysis and meta-analysis of data from existing studies and trials. Methods Search strategy and study selection Our systematic literature search was performed according to MOOSE [5], Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)(S1 File), and Cochrane guidelines. We ran searches using EMBASE (1947±Oct. 2017) (S2 File), MEDLINE (1950±Oct. 2017) (S3 File), and the Cochrane library. Two authors (first and second author) independently reviewed all articles. (...truncated)