**5. Hybrid approach for atrial fibrillation**

Nowadays the majority of ablations for symptomatic atrial fibrillation are catheter-cased. In the United States from 2000 to 2010, over 93,000 catheter ablations were performed for atrial 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 ablation, surgical ablation called Cox-Maze procedure is recommended [51].

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,


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

and bilateral thoracoscopic approaches as well as subxiphoid and laparoscopic access. Overall, hybrid ablation procedures are associated with low mortality which is up to 4%. High success rates are reported noting sinus rhythm off antiarrhythmic drugs in about 87% of cases and in about 92% when antiarrhythmic drugs are added.

In conclusion, for the success of the hybrid ablation for atrial fibrillation, a creation of a collaborative team between cardiac surgeons and electrophysiologists is crucial. This collaboration will permit important advances in improving the outcomes of procedure especially in challenging patients.
