Thoracoscopic surgical ablation or catheter ablation for patients with atrial fibrillation? A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES: There is an urgent need to understand the difference in the influence of thoracoscopic surgical ablation (TSA) and catheter ablation (CA) on clinical outcomes in patients with atrial fibrillation (AF). This meta-analysis of randomized controlled trials aimed to examine the efficacy and safety of TSA versus CA in patients with AF. METHODS: Databases including EMBASE, Clinical Trials, PubMed and Cochrane Central Registered Control System were screened for the retrieval of articles. A direct meta-analysis of TSA versus CA was conducted. The I-2 test analysis was performed to evaluate heterogeneity. The Begg-Mazumdar test and the Harbord-Egger test were used to detect publication bias. The primary efficacy outcome was freedom from atrial tachyarrhythmia, while the primary safety outcome was severe adverse event (SAE) occurrence. RESULTS: Of the 860 identified articles, 6, comprising 466 participants, were finally included. The rate of freedom from AT was higher in the TSA group (75%) than in the CA group (57.1%) (odds ratio 0.41; 95% confidence interval 0.2-0.85; P = 0.02; I-2 = 57%). A larger number of SAEs were observed in the TSA group than in the CA group (odds ratio 0.16; 95% confidence interval 0.006-0.46; P = 0.0006; I-2 = 44%). The result of the subgroup analysis of 3 studies that enrolled AF patients without a history of ablation showed that the incidence of AT was comparable in both arms. The ablation procedure and hospitalization durations were longer in the TSA arm. CONCLUSIONS: In our study, TSA was associated with better efficacy but a higher rate of SAEs compared to CA. In addition, TSA did not show better efficacy results as the first invasive procedure in the sub-analysis of patients with paroxysmal AF or early persistent AF. Therefore, doctors should recommend either TSA or CA to patients with AF after due consideration of the aforementioned findings.