Hybrid vs. endocardial catheter ablation for persistent and longstanding atrial fibrillation: a systematic review and meta-analysis
A Menezes Junior, B R Silva, A V Z Barbosa, P L A Alencar, S M BotelhoAbstract
Background
Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, with persistent and longstanding forms remaining challenging to treat. While endocardial catheter ablation (CA) is widely used, its efficacy declines in advanced AF due to atrial remodeling. Hybrid ablation (HA), which integrates epicardial and endocardial techniques, has emerged as a promising approach to improve outcomes; however, its relative efficacy and safety remain unclear.
Purpose
This systematic review and meta-analysis were conducted to compare the procedural efficacy and safety of hybrid ablation versus endocardial catheter ablation alone for the treatment of symptomatic, drug-refractory persistent or long-standing persistent atrial fibrillation.
Methods
We conducted a systematic review and meta-analysis of randomized controlled trials and observational studies comparing HA with CA in adults with persistent or longstanding AF. Literature searches were performed in PubMed, Embase, and Cochrane up to November 2025. The primary efficacy endpoint was freedom from AF. Secondary outcomes included freedom from any arrhythmia, freedom from anti-arrhythmic drugs (AADs), repeat ablation, and arrhythmia recurrence. Safety outcomes included major complications, stroke, tamponade, phrenic nerve paralysis, death, and cardioversion. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using random-effects models.
Results
Eight studies comprising 907 patients (478 HA, 429 CA) were included. There was no significant difference in freedom from AF (OR 2.38; 95% CI 0.66–8.65; p=0.1874) and arrhythmia recurrence (OR 1.66; 95% CI 0.31–9.06; p=0.5562) between the two groups. However, Hybrid Ablation (HA) significantly improved freedom from arrhythmia (regardless of AADs) (OR 3.36; 95% CI 2.16–5.23; p<0.0001) and freedom from Anti-Arrhythmic Drugs (AADs) (OR 3.25; 95% CI 2.20–4.82; p<0.0001). (HA) was also associated with a lower rate of repeat ablation than Catheter Ablation (CA) (OR 0.28; 95% CI 0.09–0.90; p=0.0332). Regarding safety and procedural outcomes, HA was also associated with increased major complications (OR 2.73; 95% CI 1.18–6.27; p=0.018), longer procedure time, and shorter fluoroscopy time, as shown in Figures 1 and 2.
Conclusion
Hybrid ablation provides superior rhythm outcomes compared to catheter ablation in non-paroxysmal AF, at the cost of higher complication rates and procedural burden. Careful patient selection and performance in experienced centers are essential to balance efficacy and safety.Primary endpointsSecondary Endpoints