Hybrid Versus Catheter Ablation in Persistent Atrial Fibrillation - HARTCAP-AF

Contribution To Literature:

The HARTCAP-AF trial showed that hybrid (surgical + catheter) ablation resulted in more patients in sinus rhythm and off antiarrhythmic drug therapy compared with catheter ablation.


The goal of the trial was to evaluate hybrid (surgical + catheter) ablation compared with catheter ablation among patients with persistent atrial fibrillation.

Study Design

  • Randomized
  • Parallel

Patients with persistent atrial fibrillation were randomized to hybrid (surgical + catheter) ablation (n = 19) vs. catheter ablation (n = 22).

  • Total number of enrollees: 41
  • Duration of follow-up: 12 months
  • Mean patient age: 64 years
  • Percentage female: 5%
  • Percentage with diabetes: 21%

Inclusion criteria:

  • >18 years of age
  • Symptomatic persistent atrial fibrillation
  • Refractory to antiarrhythmic drug
  • No prior catheter ablation

Exclusion criteria:

  • Left atrial diameter >60 mm
  • Contraindication for ablation or prior ablation
  • Body mass index >40 kg/m2
  • History of cardiac surgery
  • Limited life expectancy
  • Pregnancy

Principal Findings:

The primary outcome, freedom from any atrial tachyarrhythmia >5 minutes off antiarrhythmic drugs at 12 months, occurred in 89% of the hybrid ablation group vs. 41% of the catheter ablation group (p = 0.002).

Secondary outcomes:

  • Major adverse events: 5% in the hybrid ablation group vs. 5% in the catheter ablation group
  • Serious adverse events: 21% in the hybrid ablation group vs. 14% in the catheter ablation group (p = 0.69)


Among patients with persistent atrial fibrillation, hybrid (surgery + catheter) ablation was superior to catheter ablation. Hybrid ablation improved freedom from atrial fibrillation off antiarrhythmic drug therapy at 12 months. There was one major adverse event in each treatment group; one pericarditis/pericardiocentesis in the hybrid ablation group and one bleeding event in the catheter ablation group. Serious adverse events were similar between treatment groups. This trial was relatively small; however, the results are encouraging in support of a hybrid approach to treat of persistent atrial fibrillation.


van der Heijden CA, Weberndörfer V, Vroomen M, et al. Hybrid Ablation Versus Repeated Catheter Ablation in Persistent Atrial Fibrillation: A Randomized Controlled Trial. JACC Clin Electrophysiol 2023;Jan 18:[Epub ahead of print].

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias

Keywords: Ablation Techniques, Anti-Arrhythmia Agents, Anticoagulants, Arrhythmia, Sinus, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Cardiac Surgical Procedures, Pericardiocentesis, Pericarditis, Tachycardia

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