An anatomical atlas for hybrid ablation of atrial fibrillation: a step-by-step ablation guide with anatomical explanations

This review provides a detailed, image-guided anatomical description of the hybrid ablation procedure for atrial fibrillation (AF), addressing a critical need for precise anatomical knowledge in cardiac surgery. Hybrid ablation merges the durability of epicardial surgical lesions with the precision of endocardial catheter mapping, offering superior efficacy for persistent AF compared to standalone approaches. The core of this paper is a step-by-step intraoperative guide to right and left thoracoscopy, detailing trocar placement, pericardial sac dissection, and, crucially, the creation of surgical access through the transverse and oblique pericardial sinuses. High-quality perioperative images illustrate the dissection and ablation of key structures with an emphasis on the clinical anatomy of these targets, explaining their role in arrhythmogenesis. Furthermore, the review highlights the anatomical rationale for specific surgical maneuvers. Finally, we identify significant gaps in anatomical evidence, particularly concerning the vasculature of the arrhythmogenic substrates, including the pulmonary veins, vestigial fold, and left atrial appendage. This work serves as an essential anatomical atlas for cardiac surgeons and electrophysiologists, with the aim of enhancing the safety, efficacy, and anatomical understanding of the hybrid ablation procedure.