Perspective:

Hybrid ablation has been developed to address the complex arrhythmogenic substrate often found in patients with nonparoxysmal atrial fibrillation. The procedure entails thoracoscopic ablation followed by catheter ablation. In this study, surgical ablations were performed using a thoracoscopic, off-pump, epicardial approach with the goal to create a circumferential lesion anterior to the pulmonary veins to isolate all the pulmonary veins together with the posterior aspect of the left atrium (i.e., a box lesion set) in one fell swoop. The electrophysiology (EP) study and catheter ablation were performed approximately 2-3 months after the surgical ablation. The EP study was used to confirm the isolation of the box lesion, create a mitral isthmus line, and ablate the cavotricuspid isthmus. This study did not have a control arm, and a direct comparison with catheter-only procedure is not possible. However, this manuscript demonstrates that this resource-intensive two-step procedure was associated with relatively poor efficacy, a high risk of silent cerebral ischemia, and postoperative cognitive decline, raising the question of the procedure’s place in the rhythm control armamentarium.