Building a surgical atrial fibrillation program: Programmatic evolution, safety, and three-year rhythm outcomes of hybrid ablation.

Objective: Surgical ablation is a guideline-supported treatment for symptomatic persistent and long standing persistent atrial fibrillation (AF) refractory to catheter ablation, but how a program is built, refined, and sustained has not been described. We sought to describe the development of a de novo surgical ablation program as well as its procedural evolution, safety profile, and long-term rhythm outcomes. Methods: We reviewed the programmatic evolution of our program and growth of procedural volume and complexity. We also analyzed the long-term electrophysiologic and safety outcomes of all patients undergoing minimally invasive surgical ablation from 2020 to 2024. Rhythm assessment was performed using 12 lead ECG, wearable monitor, implantable loop recorder, or ICD/PPM interrogation following a 3-month blanking period after endocardial ablation. Results: One hundred and twenty-five consecutive patients undergoing hybrid surgical ablation between 2020 and 2024 at our institution were analyzed. Of which, one hundred and twelve had sufficient follow-up data. At 1, 2, and 3 years of follow-up, 94%, 85%, and 70% of patients were in normal sinus rhythm with 67% of those patients remaining off class I/III antiarrhythmic therapy at three years. There were no peri-procedural deaths, conversions to sternotomy, tamponade, strokes, or atrio-esophageal fistulae. Thirty-day adverse events occurred in 4 patients (3.6%) and included three patients with pericarditis and one patient with transient phrenic nerve palsy. The volume at our institution increased fourfold during the study period paralleled by increasing complexity and scope of operations. Conclusions: This experience provides a roadmap for developing a multifaceted hybrid ablation program with excellent safety and durable rhythm outcomes.