A TX electrophysiologist put out a very good video on YouTube about three years ago where she talks about a hybrid procedure. Her procedure is a two-pronged approach where they go under the sternum, up behind the heart, and do ablation on the exterior of the LA. A week or two later, they do a regular 'groin access' catheter ablation and do the inside of the atrial wall, which would almost certainly include a PVI. However, these days, it seems that they're finding the left atrial appendage (LAA) is at least a danger point of origin for lethal clots if not for some re-entrant foci for spurious signal as well. That's why we read about the Watchman implantation so much on this and on other fora. The Watchman closes off the LAA and makes it impervious to blood. No blood in the LAA means no chance of clots forming there, meaning no risk of stroke originating in the LAA.

I am unclear of what your 'hybrid' procedure is. It seems new to me.

I have questions, and I urge you to find the answers to them:
a. Why warfarin? Why not a more modern DOAC like apixaban (brand name Eliquis)? Warfarin means you need to have two blood assays a month (called INR) to get titers to see if you are getting the correct dose. A pain where the sun don't shine...if you ask me;

b. If warfarin is meant to help to reduce the clot's size, why has it not seemed to work? At what point do we throw in the towel and decide that the clot must be retrieved mechanically....IF...that is the next course of action or is possible?

c. When I go off warfarin, will I necessarily be prescribed a DOAC and have to take it for the foreseeable future, or even for life as most everyone with heart arrhythmias must do?

d. What will the hybrid procedure do, including adding to any risks inherent with such procedures, that a simple RF or PFA ablation procedure can't do?

e. What does he/she mean by 'exclusion of the left atrium' (sic)? I have never seen that term or descriptor of a procedure meant to restore rhythm, or to reduce risk of stroke if that is what it intends.

f. I'm the type of guy who must know all I can about what's in front of me, smoke intervening or not. So, when they told me I had enlargement of my LA, the written document I was given conveniently included their own descriptor of 'moderate enlargement', which for me helped to situate my LA in the grand scheme of all LA enlargements. There's no number that meant anything to me, but the descriptor at least helped me to appreciate that I wasn't in the upper range of 'Holy cow! That's one large atrium!'

It is a daunting task trying to read, to listen, and to experience your own affliction, and to try to make them all intersect nicely in a way that you can calm yourself and to manage your own case as you know is best for you. For me, early in my own paroxysmal AF I began to read and to try to figure out what I should do for myself. It became immediately clear that, since I was heavily symptomatic, a mechanical intervention was going to be called for in the long run. I learned that it is a progressive disorder, sadly, and that management of it early, and keeping on top of the runaway atrium, is very important. I knew right away that I wanted an ablation once I understood how the atrium begins to fibrillate, and the reasoning behind the ablation procedure. It was a no brainer. Happily, my cardiologist quickly referred me to an electrophysiologist as soon as my progression became evident and my AF began to happen almost weekly instead of once a year, as it did for the first two years. I had to have two ablations, unfortunately, but the second 'got it'...finally...and I have been free from AF or even PACs for 16 months now.

Final comment from me unless you have more pointed questions: Read. When you've finished one article, you should have a list of two or more questions to research. Keep searching and reading. Form an idea of what you have, and then how you'd like it controlled. The more you sound informed (without being a pain in the patoot as a patient), the more impressed and respectful your help will be and they'll know you take your health seriously.