**6. Conclusions**

fibrillation [49]. However, the outcomes of catheter ablation for patients with significant valve disease and long-standing persistent atrial fibrillation remain poor [50]. For patients who have valvular heart disease or patients who are refractory to antiarrhythmic drugs or catheter

The hybrid approach for atrial fibrillation represents a collaborative between cardiac surgeons and cardiologists utilizing the strengths of both techniques in order to achieve outcomes that maximize the success rates and minimize the procedural complications. There are several potential advantages to a hybrid approach [50]. From a surgical standpoint, direct visualization allows surgeons to perform aggressive ablation at sites which may be challenging for catheter ablation due to risk of injuring esophagus or phrenic nerves, and also allows surgeons to confirm of transmurality of ablation. Moreover, the ability to exclude the left atrial appendage serves to potentially eliminate need for anticoagulation. On the other hand, catheter ablation allows more complex mapping of the left atrium for either complex fractionated atrial electrograms or rotors. Hybrid procedures incorporate both an epicardial surgical ablation and endocardial catheter ablation [52]. The procedure can be done in either one-staged or two-staged fashion. The outcomes of hybrid approach for atrial fibrillation in previous studies are shown in **Table 2**. While all procedures were done through minimally invasive approach, the approach varied with right,

**(months)**

Krul et al. [64] 2011 31 12 0 86 –

2011 15 20.7 ± 4.5 0 86.7 93.3

2012 26 12 0 92 –

2012 36 30 0 77.7 91.6

2012 50 24 4 87 –

2013 35 12 0 91.4 –

2013 45 28 ± 1.7 0 88.9 –

2014 73 12 0 52 80

2015 50 12 0 84 94

Gehi et al. [69] 2013 101 12 2 60.7 73.3

**Mortality (%) Success rate off** 

**AA drugs (%)**

**Success rate on AA drugs (%)**

ablation, surgical ablation called Cox-Maze procedure is recommended [51].

**Study Year Number of pts Follow-up** 

Mahapatra et al. [63]

264 Interventional Cardiology

Pison et al. [65]

Muneretto et al. [66]

Gersak et al. [67]

La Meir et al. [68]

Bisleri et al. [70]

Gersak et al. [71]

Bulava et al. [72]

*Note*: AA, antiarrhythmic.

**Table 2.** Outcomes of hybrid approach for atrial fibrillation.

Nowadays, the cases of patients who suffer from cardiovascular disease are more and more complex. Along with the technological advancement, patients who used to be thought inoperable can be treated by a new technology with a reasonable risk. Interventional cardiologists tend to be more invasive in their field, whereas cardiac surgeons tend to seek for minimally invasive approach. There are advantages and disadvantages in both surgery and interventions. The rational for hybrid procedures is to achieve the best outcome by combining the strengths of both surgery and interventional procedures. The key point for the success of hybrid procedures is the collaboration between interventional cardiologists and cardiac surgeons. In the current era, patient selection and indications for each procedure must be well discussed in a well-functioning Heart Team.
