Hybrid surgical-catheter ablation is a treatment for people with two types of atrial fibrillation, or AFib: persistent AFib and long-standing persistent AFib.

AFib is a condition in which abnormal electrical signals in the heart disrupt its normal rhythm, resulting in an irregular and often faster-than-normal heartbeat. Ablation is a commonly used treatment for AFib. It involves administering heat, cold, or other forms of energy to scar areas of heart tissue that generate or conduct the abnormal electrical signals responsible for AFib. Because the scarred tissue can no longer generate or conduct the electrical signals, the treatment helps the heart to beat with a normal rhythm and at a normal rate.

Ablation for AFib can be performed via surgical or catheter ablation. Surgical ablation involves a surgical procedure to access the heart. A heart surgeon then ablates areas of tissue on the heart’s outer surface (epicardium) and/or inner surface (endocardium). Catheter ablation, however, is not a surgical procedure. It is performed by an electrophysiologist, a doctor who specializes in heart arrhythmias (or irregular heartbeats). For catheter ablation, an electrophysiologist inserts a thin tube called a catheter into a blood vessel, guiding it into the heart, and then, using a device at the tip of the catheter, ablating tissue on the inner surface of the heart.

Surgical ablation and catheter ablation may be used on their own to treat AFib. However, by combining them, hybrid surgical-catheter ablation allows doctors to treat abnormal electrical signals that occur on both the inner and outer surfaces of the heart. In the hybrid procedure the surgical ablation is performed only on the outer surface of the heart. Studies have found that hybrid ablation has good outcomes and can help restore normal heart rhythm in people with persistent or long-standing persistent AFib.

AFib is the most common type of heart arrhythmia.

The heart has four chambers: Two upper atria and two lower ventricles. In a healthy heart, these chambers work in a coordinated manner, contracting and pumping blood at a carefully controlled pace and rhythm.

The contractions of the heart’s chambers are regulated by electrical signals. The electrical signals are generated in the sinoatrial node (also known as the SA or sinus node), a part of the right atrium, the heart’s upper right chamber. When the SA node generates a signal, the electrical impulse stimulates the two atria to contract, which in turn pumps blood to the two ventricles. The electrical signal then travels down the heart and stimulates the ventricles to contract, causing them to pump blood to the lungs and to the rest of the body.

The SA node is considered the heart’s natural pacemaker. It can send electrical signals at a steady rate, or it can speed up or slow down the rate of signals it sends, causing the heart to beat faster or slower, depending on the body’s needs (e.g., it might speed up during exercise and slow down while at rest or when sleeping).

In AFib, abnormal electrical impulses are generated from multiple sites in the atria, rather than solely from the SA node. These abnormal electrical signals cause the atria to fibrillate, or quiver. The heart rhythm becomes irregular, and the heart often beats faster than normal.

Because the atria do not contract properly, they are unable to efficiently pump blood to the ventricles. This can cause blood to pool in the atria, which raises the risk for blood clots and stroke. Additionally, because the heart’s four chambers no longer work in coordination with one another, the amount of blood that is pumped around the body is reduced.

There are four main types of AFib. They are categorized based on how long the condition lasts:

• Paroxysmal AFib: Less than seven days.
• Persistent AFib: Seven days or longer.
• Long-standing persistent AFib: 12 months or longer.
• Permanent AFib: Remains irregular despite treatment.

Hybrid surgical-catheter ablation is a treatment approach for people with persistent or long-standing persistent AFib. It combines surgical ablation and catheter ablation:

• Surgical ablation. In this procedure, a heart surgeon performs a surgical procedure to gain access to the patient’s heart. The surgeon then uses a device to administer radiofrequency energy (heat) or cryothermal energy (freezing) to tissue on the outer surface of the heart and/or to the inner surface. The energy scars the tissue, preventing it from generating or conducting electrical signals. In the most common procedure, known as the Maze procedure (or the Cox-Maze or Cox-Maze IV procedure), the surgeon ablates lines of tissue in the atria that block the abnormal electrical signals that cause AFib.
  
  Surgical ablation may be performed via open heart surgery or minimally invasive surgery; however, it is usually reserved for patients who are already undergoing open heart surgery for another reason.
  
  In hybrid surgical-catheter ablation, surgical ablation is performed either using a small incision in the lower chest or using minimally invasive robotic techniques.
• Catheter ablation. Catheter ablation is a nonsurgical procedure for treating AFib. In this procedure, one or more catheters are inserted into a blood vessel, usually in the groin, then directed through the blood vessel to the heart. Once in the heart, the electrophysiologist identifies areas that require treatment, then uses heat, cold, or another form of energy to scar areas of tissue on the inner surface of the heart. While catheter ablation tends to have good outcomes for people with paroxysmal AFib, outcomes are less favorable for those with persistent or long-standing persistent AFib.

Hybrid surgical-catheter ablation combines the advantages of surgical and catheter ablation and addresses abnormal electrical activity on the outer and inner surfaces of the heart. It may be performed simultaneously, in a single procedure, or in two stages, in which the surgical ablation is performed first, and catheter ablation is done at a later time, typically days, weeks, or months later.

Both simultaneous and staged hybrid ablation procedures have advantages and disadvantages:

• When surgical and catheter ablation are performed simultaneously, the electrophysiologist and cardiac surgeon can collaborate and coordinate with one another during the procedure. It also involves a single hospital stay, though it requires a longer time under anesthesia.
• The two-stage procedure allows doctors to evaluate the outcome of the surgical ablation before performing catheter ablation, though it requires two hospital stays.

AFib treatment aims to prevent stroke, restore a normal heart rate or rhythm, relieve symptoms, and prevent the condition from worsening. Treatments include lifestyle changes, medications, cardioversion (delivering an electrical shock to the heart via electrode patches or paddles that are placed on the chest or on the chest and back), and ablation procedures, including catheter, surgical, and hybrid surgical-catheter ablation.

Hybrid surgical-catheter ablation is used to treat people with persistent or long-standing persistent AFib that is causing symptoms and does not respond to anti-arrhythmic medications (drugs used to treat abnormal heart rhythms). People who have previously been treated with catheter ablation can still undergo a hybrid procedure. However, hybrid surgical-catheter ablation is typically not an option for people who have had a previous heart surgery.

Recovery from one-stage hybrid ablation: One-stage hybrid surgical-catheter ablation involves having both surgical and catheter ablation on the same day under the same general anesthesia.

After one-stage hybrid ablation, you will spend the night or a few nights in the hospital, where health care providers will closely monitor your heart rhythm and the rest of your recovery. They will also administer pain and other medications as necessary, including blood thinners.

After leaving the hospital, you should avoid vigorous exercise and lifting heavy items for two weeks or as advised by your doctor.

Recovery from two-stage hybrid ablation: Two-stage hybrid surgical-catheter ablation involves two recovery periods, one for the surgical ablation and another for catheter ablation:

• Recovery from surgical ablation. After surgical ablation, you will spend the night or a few nights in the hospital, where health care providers will closely monitor your heart rhythm and the rest of your recovery. They will also administer pain and other medications as necessary, including blood thinners.
  
  After leaving the hospital, you should avoid vigorous exercise and lifting heavy items for two weeks or as advised by your doctor.
• Recovery from catheter ablation. Similarly, after catheter ablation, health care providers will monitor your heart rhythm and recovery for several hours. Some people may be able to go home the same day as the procedure while others will spend the night in the hospital.

After the procedures, you will need to take blood thinners to reduce the risk of blood clots. Before you return home, your doctor will give you instructions regarding these and any other medications you are prescribed after the procedure.

Hybrid ablation performed at a referral center is a very safe procedure. However, risks of hybrid ablation for AFib include:

• Bleeding
• Stroke
• Heart perforation (tear or rupture of a wall of one of the heart’s chambers)
• Pericardial effusion (blood in the sac around the heart)
• Damage to phrenic nerve (a nerve that controls the diaphragm, playing a key role in breathing)
• Atrio-esophageal fistula (development of an abnormal connection between the heart’s atrium and the esophagus)
• Need for a pacemaker

In general, the outlook for people with persistent or long-standing AFib who undergo hybrid surgical-catheter ablation is favorable.

For people with paroxysmal AFib, catheter ablation alone is often an effective treatment and typically results in good outcomes. Unfortunately, for people with persistent or long-standing persistent AFib, catheter ablation alone has much lower success rates.

Hybrid surgical-catheter ablation, on the other hand, has been found to be more effective than catheter ablation alone in treating persistent and long-standing persistent AFib. Studies have found that the procedure successfully restores a normal heart rhythm in around 70% to 80% of people with persistent or long-standing persistent AFib.

“At Yale, it is our privilege to provide this hybrid approach for AFib ablation, especially for patients with long-standing persistent AFib who might have had multiple unsuccessful catheter ablations in the past,” says Fabio Ramponi, MD, a Yale Medicine cardiac surgeon who specializes in heart, lung, and vascular surgery. “We offer a ‘one-stage procedure’ which involves having both surgical and catheter ablation on the same day under the same general anesthesia. This is very convenient for our patients as they have up to an 80% chance of regaining long-term normal heart rhythm with one hospital admission.”