AIMS: Data on the hybrid atrial fibrillation (AF) treatment are lacking in patients with structural heart disease undergoing concomitant CryoMaze procedures. The aim was to assess whether the timely pre-emptive catheter ablation would achieve higher freedom from AF or atrial tachycardia (AT) and be associated with better clinical outcomes than surgical ablation alone. METHODS AND RESULTS: The trial investigated patients with non-paroxysmal AF undergoing coronary artery bypass grafting and/or valve repair/replacement with mandatory concomitant CryoMaze procedure who were randomly assigned to undergo either radiofrequency catheter ablation [Hybrid Group (HG)] or no further treatment (Surgery Group). The primary efficacy endpoint was the first recurrence of AF/AT without class I or III antiarrhythmic drugs as assessed by implantable cardiac monitors. The primary clinical endpoint was a composite of hospitalization for arrhythmia recurrence, worsening of heart failure, cardioembolic event, or major bleeding. We analysed 113 and 116 patients in the Hybrid and Surgery Groups, respectively, with a median follow-up of 715 (IQR: 528-1072) days. The primary efficacy endpoint was significantly reduced in the HG [41.1% vs. 67.4%, hazard ratio (HR) = 0.38, 95% confidence interval (CI): 0.26-0.57, P < 0.001] as well as the primary clinical endpoint (19.9% vs. 40.1%, HR = 0.51, 95% CI: 0.29-0.86, P = 0.012). The trial groups did not differ in all-cause mortality (10.6% vs. 8.6%, HR = 1.17, 95%CI: 0.51-2.71, P = 0.71). The major complications of catheter ablation were infrequent (1.9%). CONCLUSION: Pre-emptively performed catheter ablation after the CryoMaze procedure was safe and associated with higher freedom from AF/AT and improved clinical outcomes.

3rd Faculty of Medicine Charles University and University Hospital Královské Vinohrady Prague Czechia

Cardilogy Department Hospital Agel Třinec Podlesí Třinec Czechia

Cardilogy Department Masaryk Hospital Ústí nad Labem Czechia

Cardiology Department Institute for Clinical and Experimental Medicine Prague Czechia

Centre of Cardiovascular Surgery and Transplantation Brno Czechia

Faculty of Biomedical Engineering Czech Technical University Prague Kladno Czechia

Faculty of Health and Social Sciences University of South Bohemia in České Budějovice and Cardiac Centre České Budějovice Hospital B Němcové 54 370 01 České Budějovice Czechia

Faculty of Medicine and Dentistry Palacký University and University Hospital Olomouc Olomouc Czechia

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Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol 1998;82:2N–9N. PubMed

Benjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham heart study. Circulation 1998;98:946–52. PubMed

Banach M, Mariscalco G, Ugurlucan M, Mikhailidis DP, Barylski M, Rysz J. The significance of preoperative atrial fibrillation in patients undergoing cardiac surgery: preoperative atrial fibrillation—still underestimated opponent. Europace 2008;10:1266–70. PubMed

Grigioni F, Avierinos J-F, Ling LH, Scott CG, Bailey KR, Tajik AJet al. . Atrial fibrillation complicating the course of degenerative mitral regurgitation determinants and long-term outcome. J Am Coll Cardiol 2002;40:84–92. PubMed

Cappello IA, Pannone L, Della Rocca DG, Sorgente A, Del Monte A, Mouram Set al. . Coronary artery disease in atrial fibrillation ablation: impact on arrhythmic outcomes. Europace 2023;25:euad328. PubMed PMC

Gammie JS, Laschinger JC, Brown JM, Poston RS, Pierson RN, Romar LGet al. . A multi-institutional experience with the CryoMaze procedure. Ann Thorac Surg 2005;80:876–80. PubMed

Budera P, Straka Z, Osmancik P, Vanek T, Jelinek S, Hlavicka Jet al. . Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study. Eur Heart J 2012;33:2644–52. PubMed PMC

Hanke T, Charitos EI, Stierle U, Sievers H-H, Misfeld M. Intermediate outcome of surgical atrial fibrillation correction with the CryoMaze procedure. Ann Thorac Surg 2010;89:340–1. PubMed

Gammie JS, Didolkar P, Krowsoski LS, Santos MJ, Toran AJ, Young CAet al. . Intermediate-term outcomes of surgical atrial fibrillation correction with the CryoMaze procedure. Ann Thorac Surg 2009;87:1452–9. PubMed

Watkins AC, Young CA, Ghoreishi M, Shorofsky SR, Gabre J, Dawood MYet al. . Prospective assessment of the CryoMaze procedure with continuous outpatient telemetry in 136 patients. Ann Thorac Surg 2014;97:1191–8. PubMed

McElderry HT, McGiffin DC, Plumb VJ, Nanthakumar K, Epstein AE, Yamada Tet al. . Proarrhythmic aspects of atrial fibrillation surgery. Circulation 2008;117:155–62. PubMed

Wazni OM, Saliba W, Fahmy T, Lakkireddy D, Thal S, Kanj Met al. . Atrial arrhythmias after surgical maze findings during catheter ablation. J Am Coll Cardiol 2006;48:1405–9. PubMed

Eisenberger M, Bulava A, Mokracek A, Hanis J, Kurfirst V, Dusek L. Sequential hybrid surgical CryoMaze and transvenous catheter ablation of atrial fibrillation. Pacing Clin Electrophysiol 2015;38:1379–85. PubMed

Bulava A, Mokráček A, Wichterle D, Budera P, Osmančík P, Kačer Pet al. . Sequential hybrid ablation versus surgical CryoMaze alone for treatment of atrial fibrillation (SurHyb trial): a protocol of the multicentre randomized controlled trial. J Appl Biomed 2023;21:67–72. PubMed

Calkins H, Hindricks G, Cappato R, Kim Y-H, Saad EB, Aguinaga Let al. . 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2018;20:e1–160. PubMed PMC

Putter H, Fiocco M, Geskus RB. Tutorial in biostatistics: competing risks and multi-state models. Stat Med 2007;26:2389–430. PubMed

Austin PC, Fine JP. Practical recommendations for reporting Fine-Gray model analyses for competing risk data. Stat Med 2017;36:4391–400. PubMed PMC

Fine JP, Gray RJ. A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc 1999;94:496–509.

McCarthy PM, Davidson CJ, Kruse J, Lerner DJ, Braid-Forbes MJ, McCrea MMet al. . Prevalence of atrial fibrillation before cardiac surgery and factors associated with concomitant ablation. J Thorac Cardiovasc Surg 2020;159:2245–2253 e2215. PubMed

January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jret al. . 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014;130:e199–267. PubMed PMC

Badhwar V, Rankin JS, Damiano RJ Jr., Gillinov AM, Bakaeen FG, Edgerton JRet al. . The society of thoracic surgeons 2017 clinical practice guidelines for the surgical treatment of atrial fibrillation. Ann Thorac Surg 2017;103:329–41. PubMed

Gammie JS, Didolkar P, Krowsoski LS, Santos MJ, Toran AJ, Young CAet al. . Intermediate-term outcomes of surgical atrial fibrillation correction with the CryoMaze procedure. Ann Thorac Surg 2009;87:1452–8; discussion 1458–1459. PubMed

Gillinov AM, Gelijns AC, Parides MK, DeRose JJ Jr, Moskowitz AJ, Voisine Pet al. . Surgical ablation of atrial fibrillation during mitral-valve surgery. N Engl J Med 2015;372:1399–409. PubMed PMC

Gaita F, Ebrille E, Scaglione M, Caponi D, Garberoglio L, Vivalda Let al. . Very long-term results of surgical and transcatheter ablation of long-standing persistent atrial fibrillation. Ann Thorac Surg 2013;96:1273–8. PubMed

Pannone L, Mouram S, Della Rocca DG, Sorgente A, Monaco C, Del Monte Aet al. . Hybrid atrial fibrillation ablation: long-term outcomes from a single-centre 10-year experience. Europace 2023;25:euad114. PubMed PMC

Magni FT, Al-Jazairi MIH, Mulder BA, Klinkenberg T, Van Gelder IC, Rienstra Met al. . First-line treatment of persistent and long-standing persistent atrial fibrillation with single-stage hybrid ablation: a 2-year follow-up study. Europace 2021;23:1568–76. PubMed PMC

de Asmundis C, Chierchia GB, Mugnai G, Van Loo I, Nijs J, Czapla Jet al. . Midterm clinical outcomes of concomitant thoracoscopic epicardial and transcatheter endocardial ablation for persistent and long-standing persistent atrial fibrillation: a single-centre experience. Europace 2017;19:58–65. PubMed

Bulava A. Hybrid procedures for persistent atrial fibrillation: necessity and timing of the catheter ablation stage. J Thorac Dis 2018;10:E83–6. PubMed PMC

van der Heijden CAJ, Weberndörfer V, Vroomen M, Luermans JG, Chaldoupi SM, Bidar Eet al. . Hybrid ablation versus repeated catheter ablation in persistent atrial fibrillation: a randomized controlled trial. JACC Clin Electrophysiol 2023;9:1013–23. PubMed

Doll N, Weimar T, Kosior DA, Bulava A, Mokracek A, Mönnig Get al. . Efficacy and safety of hybrid epicardial and endocardial ablation versus endocardial ablation in patients with persistent and longstanding persistent atrial fibrillation: a randomised, controlled trial. EClinicalMedicine 2023;61:102052. PubMed PMC

DeLurgio DB, Crossen KJ, Gill J, Blauth C, Oza SR, Magnano ARet al. . Hybrid convergent procedure for the treatment of persistent and long-standing persistent atrial fibrillation: results of CONVERGE clinical trial. Circ Arrhythm Electrophysiol 2020;13:e009288. PubMed

Packer DL, Mark DB, Robb RA, Monahan KH, Bahnson TD, Poole JEet al. . Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA 2019;321:1261–74. PubMed PMC

Brachmann J, Sohns C, Andresen D, Siebels J, Sehner S, Boersma Let al. . Atrial fibrillation burden and clinical outcomes in heart failure: the CASTLE-AF trial. JACC Clin Electrophysiol 2021;7:594–603. PubMed

Sohns C, Fox H, Marrouche NF, Crijns H, Costard-Jaeckle A, Bergau Let al. . Catheter ablation in End-stage heart failure with atrial fibrillation. N Engl J Med 2023;389:1380–9. PubMed

Lesion durability found during mandated percutaneous catheter ablation after surgical cryo-ablation for treatment of non-paroxysmal atrial fibrillation