Atrial fibrillation (AF) is one of the leading causes of stroke and heart failure. It is also a major cause of hospitalizations and mortality (Stewart, Wattigney, and Wolf). Patients with atrial fibrillation (AF) who are intolerant to Class I and III antiarrhythmic drugs often require endocardial ablation, which can include pulmonary vein isolation (PVI) using radiofrequency (RF) catheter ablation or cryoballoon ablation (Medtronic, MN) and reported success rates vary (Calkins et al). In patients with persistent and long standing persistent AF success rates may not be as high (Akoum et al) and there is little data analyzing outcomes for patients in this population (Calkins et al). Using an epicardial-endocardial, or hybrid, approach Gehi et al describes a 66% 12 month arrythmia-free survival rate following the procedure, with 37% patients still on antiarrythmic drug therapy at 12 months. Furthermore, a paper by Anderson et al reports that the hybrid ablation results in lower costs and higher quality adjusted life years for patients with non-paroxysmal AF as reported by the studie's results of fewer repeat ablations and maintenance of sinus rhythm at 5 years. Conflicting reports exist on how much endocardial catheter ablation is needed for patients in persistent and long standing persistent AF. Verma et al reports results for patients in persistent AF having endocardial PVI compared to P VI plus additional linear lesions. Eighteen month success rates for these patients were 59% and 46% respectively.