Atrial fibrillation (AF) is one of the most common arrhythmia diseases, and thromboembolic complications, impaired cardiac function and ventricular rate/rate disorders are the main hazards for patients with AF. According to relevant epidemiological surveys, the prevalence of atrial fibrillation in China is 1.83% in men and 1.92% in women over 60 years of age, with non-valvular atrial fibrillation accounting for more than 85% of the cases. Whether it is the clinical symptoms of patients or the serious adverse consequences of the disease itself, AF is likely to become a huge public health problem that needs to be addressed in the coming decades. Currently, the treatment of atrial fibrillation, especially persistent atrial fibrillation, is better with surgery than with medication. Minimally invasive surgery and catheter ablation procedures for the treatment of atrial fibrillation have been developing in parallel and continuously, and play a very important role in the treatment of atrial fibrillation. In terms of overall treatment outcome, the success rate of minimally invasive surgery for a single ablation is over 90%, much higher than the success rate of catheter ablation of about 50%, but there is still no single technique that can achieve a 100% success rate for the treatment of persistent, refractory atrial fibrillation. Minimally invasive surgery ablation from the epicardium and catheter ablation from the endocardium, both of which have their own advantages and shortcomings, can greatly improve the success rate of persistent, refractory atrial fibrillation if the two techniques are applied simultaneously in the treatment of atrial fibrillation by combining epicardial and endocardial ablation and electrophysiological marker measurement to form a “hybrid” technique. This article introduces the progress of minimally invasive surgical/catheter ablation and the combined “hybrid” technique for the treatment of atrial fibrillation based on the author’s experience in applying minimally invasive surgical/catheter “hybrid” ablation for the treatment of atrial fibrillation. Catheter ablation technique Catheter ablation technique is performed through percutaneous puncture in the endocardium to isolate the pulmonary veins and left atrium for ablation. However, due to the limitations of catheter ablation technology, the success rate of ablation is still low and the recurrence rate is high, especially in persistent atrial fibrillation, the success rate of one-time ablation is less than 30% and the success rate after multiple ablations is about 50%. The success rate 6 years after single catheter ablation was reported internationally to be 23%, with 36% for paroxysmal AF and 15% for persistent AF. Although catheter ablation has disadvantages such as poor ablation line continuity and wall permeability, low single cure rate, high percentage of patients repeating treatment, and patients receiving high doses of X-rays, catheter ablation still has certain advantages: detailed electrophysiological markings of the endocardium can be performed, and ablation of the mitral and tricuspid isthmus can be performed, making it easier for the patient’s heart to accept. So, what exactly is the reason for the low success rate of catheter ablation? This is the reality that we must face. First, endocardial radiofrequency ablation is difficult to achieve transmural injury at each ablation site, with the result that 80% of patients with atrial fibrillation recurrence are found to have some kind of pulmonary vein potential recovery; second, during catheter ablation, it is difficult to achieve complete bidirectional block at each ablation line and to verify bidirectional block for each ablation line, thus offsetting the additional effect of these additional ablation lines; again, the Catheter ablation does not effectively address the left auricle, the culprit of thromboembolic complications in patients with AF; if AF recurs after catheter ablation, the patient will not benefit from catheter ablation at all because there is still a risk of thrombosis, continued need for anticoagulation, etc. In addition, catheter ablation cannot deal with epicardial autonomic ganglia. In recent years, with the continuous improvement of minimally invasive surgical methods and the increasing improvement of atrial fibrillation ablation devices, the minimally invasive surgical treatment techniques for atrial fibrillation have been improved and the therapeutic effects have been enhanced. 1987, Cox designed the classic Cox maze procedure according to the mechanism of atrial fibrillation, which, despite the complexity of the procedure, ensures normal conduction of sinus excitation, avoids atrial This procedure, despite its complexity, ensured normal conduction of sinus excitation, avoided atrial folding, successfully restored atrioventricular synchronization and sinus rhythm, while eliminating the risk of thrombosis and reducing the incidence of long-term stroke. Since then, cardiac surgeons around the world have made several improvements to the traditional Cox labyrinth procedure to make it less invasive and less risky, while ensuring that the treatment outcomes are basically equivalent. Meanwhile, with the advent of new ablation devices, ablation energy and ablation strategies, atrial fibrillation treatment through minimally invasive surgery has become a new option. In 2005, Wolf first applied the maze procedure to the field of minimally invasive cardiac surgery and reported good results with pulmonary vein isolation and left olecranon resection through small bilateral chest wall incisions. Due to the high safety and effectiveness of thoracoscopically assisted and total thoracoscopic radiofrequency ablation of atrial fibrillation, it has now become an important treatment modality for isolated atrial fibrillation. However, this technique requires bilateral chest incision surgery, which is still more traumatic; in addition, this technique can only make bilateral ablation lines of circumferential pulmonary veins, and cannot make ablation lines between the pulmonary veins on both sides, which has a certain impact on the surgical effect. May’s minimally invasive atrial fibrillation ablation is a new, safe and effective treatment method for atrial fibrillation, and the surgical design is perfect: it effectively changes the status quo of catheter ablation for large atria, and provides intuitive and targeted treatment for special parts and structures of the heart (such as the left auricular region and the autonomic plexus), with the advantages of high single cure rate, small trauma, continuous ablation line and good wall penetration. At the same time, the procedure allows ablation of the epicardial autonomic ganglion and Marshall’s ligament, and resection of the left auricle. This procedure has significantly improved the ablation effect and opened up a new way for the treatment of patients with isolated atrial fibrillation. May’s minimally invasive atrial fibrillation ablation also has a success rate of about 90% for persistent atrial fibrillation, which is currently the most successful and least invasive technique internationally. For patients with postoperative recurrence, because the left heart ear is removed during the procedure, the origin of the left atrial thrombus is cleared, so there is no need to continue taking anticoagulants, reducing the associated inconvenience and medication complications. However, minimally invasive surgery also has its shortcomings. For example, due to the anatomic structure and the characteristics of minimally invasive surgical ablation procedures, it is not possible to effectively ablate the mitral and tricuspid isthmus to completely eliminate the occurrence of sinus tachycardia and atrial flutter after the procedure. After understanding the advantages and disadvantages of minimally invasive surgery and catheter ablation, it is easy to find that minimally invasive surgery has a very high surgical cure rate, but a single operation still cannot achieve a 100% success rate. Catheter ablation has an inherent deficiency in persistent atrial fibrillation, but this deficiency can be achieved by surgical ablation. Therefore, if minimally invasive surgical techniques and catheter ablation can be effectively combined to complement each other, the treatment of atrial fibrillation may achieve a “1+1>2” effect. Guided by this concept, the “hybrid” surgical strategy of minimally invasive surgery combined with catheter ablation has been developed. Atrial fibrillation “hybrid” surgery is defined as a patient receiving epicardial (minimally invasive surgery) + endocardial (catheter ablation) atrial fibrillation ablation treatment. The surgical procedure and catheter ablation may be performed simultaneously or sequentially over a period of time. The “hybrid” procedure is the highest level of treatment in the field of atrial fibrillation treatment, which is a combination of minimally invasive surgical techniques and catheter techniques, each taking advantage of the other’s strengths and complementing each other, expanding the indications for atrial fibrillation radiofrequency ablation surgery, and greatly improving the success rate of ablation in a single procedure, making the ablation rate in a single procedure basically reach 100 The success rate of single-operation ablation has been greatly improved, and the ablation rate of single-operation ablation has reached 100%. This procedure is a milestone in the treatment of atrial fibrillation, as it allows multidisciplinary and multi-skilled physicians to work closely together to terminate atrial fibrillation on the operating table. The advantages of the “hybrid” procedure are: 1) more definitive and long-lasting damage caused by the ablation line, a decisive factor in the success rate of AF treatment, which is mainly accomplished by minimally invasive surgery; 2) removal of the left auricle, thus fundamentally eliminating the risk of thrombosis and embolism due to AF, which is also accomplished by minimally invasive surgery; 3) epicardial Ablation of the vagal ganglion and Marshall’s ligament, which maximizes the elimination of the “soil” for the maintenance of atrial fibrillation, is mainly done by minimally invasive surgery; 4, electrophysiological markers are used to verify the ablation effect of all ablation lines, and some ablation points and lines are added if necessary, especially for the mitral valve, tricuspid isthmus and the borderline, which cannot be done by minimally invasive surgery. These techniques are performed by catheter ablation surgeons, especially for mitral valve, tricuspid isthmus, and borderline ablation, which cannot be performed by minimally invasive surgery. Minimally invasive surgical/catheter “hybrid” ablation techniques are the most successful procedure in the field of atrial fibrillation treatment, as they basically complete all of the currently accepted ablation and treatment components. Minimally invasive surgical/catheter “hybrid” ablation requires a highly skilled atrial fibrillation surgeon and a first-rate cardiac electrophysiologist to work closely together in order to maximize results. Different scholars have different recommendations on the choice of surgical sequence. The prevailing international view is that minimally invasive surgery should be performed first, followed by catheter ablation. This view coincides with our recommendation. The reasons are as follows: 1. The overall success rate of minimally invasive surgery is high, and almost all ablation lines and foci in the left atrium can be completed intraoperatively, and the ablation lines are complete and have good wall permeability, so there is no need for subsequent catheter ablation to supplement the ablation lines in the left atrium after surgical ablation first; 2. of excitation foci, while completing part of the ablation line, such as the ablation of the mitral and tricuspid isthmus lines. In terms of the indications for surgery, we recommend the following patients to undergo “hybrid” surgery: 1) complicated persistent atrial fibrillation, especially those with long duration (long-range persistent atrial fibrillation) and significant left atrial enlargement, who are expected to have poor results from simple minimally invasive surgery or catheter ablation; 2) patients who have failed previous catheter ablation; 3) patients who have relapsed after surgical ablation of atrial fibrillation. Those who have relapsed after ablation. The choice of minimally invasive surgical/catheter “hybrid” ablation technique There are two modes of minimally invasive surgical/catheter “hybrid” ablation technique. One is simultaneous “hybrid” surgery, that is, simultaneous ablation, where the entire procedure is performed in a “hybrid” operating room (also called a composite operating room), which must be equipped with cardiac surgery, catheterization, a DSA machine and a polyphysiological recorder. At the end of the minimally invasive surgical procedure, the cardiac physiologist is responsible for electrophysiological markers (e.g., coronary sinus electrodes and pulmonary vein electrodes) and for the completion of partial ablation of lines such as the tricuspid isthmus. This method is also known as “one-stop hybridization”, which combines the advantages of minimally invasive surgery and catheter ablation, complementing each other’s strengths and avoiding the disadvantages of surgical ablation without detailed electrophysiological markings, and also avoiding the congenital deficiency of high recurrence rate of medical ablation. It also avoids the congenital deficiency of the high recurrence rate of medical ablation. However, this type of procedure is expensive and requires multidisciplinary physician collaboration, which only a few cardiac centers in China are able to achieve. Another model is the staged “hybrid” procedure, in which the patient undergoes minimally invasive surgery first and then undergoes electrophysiologic labeling and ablation 3 to 6 months after the surgery or after the recurrence of atrial fibrillation or other atrial tachycardias. However, if a staged “hybrid” procedure is chosen, a combination of medications after minimally invasive surgery may affect the reliability of the second-stage electrophysiological markers and may mask some of the underlying lesions. These two “hybridization” approaches are preferable to simultaneous “hybridization” surgery, or “one-stop hybridization surgery,” and have yielded definitive results. Minimally invasive surgical/catheter “hybrid” ablation solves challenges that minimally invasive surgical and catheter ablation alone cannot address, such as the fact that after a failed minimally invasive surgical ablation, patients are often unlikely to undergo the procedure again, especially in the short term when repeat procedures are unlikely. In addition, the occurrence of atrial tachycardia and atrial flutter after minimally invasive surgical ablation must be resolved by electrophysiological examination and precise catheter ablation, while the success rate of reablation in cases of failed catheter ablation is still low, so it is clearly more reasonable to choose surgical ablation. Therefore, with the development of “hybrid” ablation in more centers, we have reason to believe that the future of treatment of persistent complex AF will be brighter.