Hybrid or catheter ablation: Which strategy is better for non-paroxysmal AF?

In the final results of the CEASE-AF* trial, a hybrid ablation strategy outshines a catheter ablation approach for the treatment of individuals with non-paroxysmal atrial fibrillation (AF).

“[In this analysis reporting 3-year outcomes,] the rhythm control benefit of a hybrid ablation approach exceeded that of an endocardial-only approach for non-paroxysmal AF,” said Professor Piotr Suwalski from the Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland, at EHRA 2025.

Suwalski and colleagues set out to ascertain the long-term safety and effectiveness of de novo hybrid ablation with left atrial appendage exclusion (LAAE) vs endocardial catheter ablation for non-paroxysmal AF. A total of 154 patients (mean age 60.7 years, 74.7 percent men, mean left atrial diameter 4.7 cm) were included. Of these, 80.5 percent had persistent AF (PAF) while the rest had longstanding PAF (LSPAF). [Suwalski, et al, EHRA 2025]

Participants were randomized 2:1 to either a staged hybrid ablation (epicardial pulmonary vein isolation [PVI] + posterior box + LAAE [index procedure] then endocardial mapping/ablation to address gaps [stage 2]) or catheter ablation (PVI as index procedure plus endocardial ablation as clinically indicated, prior to the beginning of follow-up).

Through 36 months, effectiveness was more than twofold higher with hybrid vs catheter ablation (61.1 percent vs 27.5 percent). A comparison between arms yielded an absolute difference of 33.6 percent (p<0.001).

The investigators defined effectiveness as freedom from AF, atrial flutter, or atrial tachycardia >30 sec in the absence of class I/III off anti-arrhythmic drugs (AADs), except previously failed AADs at doses not exceeding those that previously failed.

The findings align with those reported in previous analyses, wherein hybrid ablation with LAAE improved freedom from atrial arrhythmias by 32 percent and 33 percent through 12 and 24 months, respectively, compared with catheter ablation in this patient setting. The p-values for both timepoints were also significant (p<0.001). [EClinicalMedicine 2023;doi:10.1016/j.eclinm.2023.102052; EP Europace 2024;26:euae102.227]

Effectiveness was similarly significantly higher with hybrid vs catheter ablation in individuals with PAF (61 percent vs 32.6 percent; p=0.003), more so in the LSPAF subgroup (61.1 percent vs 0 percent; p=0.007).

Safety profile

There were statistically similar major complication rates between the hybrid and catheter ablation arms (12.7 percent vs 9.6 percent; p=0.79). Of note, this trend was already evident at 12 and 24 months. Suwalski said they were ‘very happy’ with this outcome, given that thoracoscopic procedures are ‘free ports of invasiveness’ yet there were no significant between-group differences in the long term.

Reintervention rate was significantly lower in the hybrid vs the catheter ablation arm (28.4 percent vs 56.9 percent; p<0.001). “Reintervention was defined as crossover to epicardial ablation, electrical and pharmaceutical cardioversion, pacemaker implant, implantable cardioverter defibrillator (ICD) implant, repeat ablation, surgical ablation, or other interventions,” noted Suwalski and colleagues.

Almost 18 percent of individuals in the catheter ablation arm crossed over to receive epicardial ablation. The catheter ablation arm had higher rates of cardioversions (35.3 percent vs 20 percent; p=0.043) and repeat ablations (41.2 percent vs 10.5 percent; p<0.001) than the hybrid arm.

The rates of permanent pacemaker implantation were similarly low between arms at 2 percent. Among those who received hybrid ablation, only a few received an ICD (1 percent) and other interventions (2 percent).

“The hybrid ablation benefit was durable through 36 months – which, I think, is a very important finding – without significantly increasing the complication rate and with a significantly lower reintervention rate, including repeat ablations,” said Suwalski.