Thoracoscopic Versus Catheter Ablation in Persistent Atrial Fibrillation With Enlarged Left Atrium

Pulmonary vein isolation is an established rhythm‐control therapy for symptomatic atrialfibrillation refractory to antiarrhythmic drugs. Its efficacy is lower in persistent thanin paroxysmal atrial fibrillation, and additional substrate modification of the leftatrium is frequently required.Percutaneous catheter ablation (radiofrequency, cryoballoon or PFA) and thoracoscopicsurgical ablation are both used in current practice. Thoracoscopic ablation additionallyallows epicardial pulmonary vein isolation, ganglionated plexi ablation, dissection ofthe ligament of Marshall, and left atrial appendage exclusion, at the cost of a longerhospital stay and a higher incidence of post‐procedural pericarditis. Recent trials haveshown broadly comparable efficacy and safety between the two approaches, so both are usedinterchangeably in practice.In a retrospective analysis of the institutional ablation registry at the study site,overall outcomes of the two strategies were comparable, but among patients with anenlarged left atrium thoracoscopic ablation was associated with significantly lowerrecurrence of atrial tachyarrhythmia. Because that finding came from a subgroup of aretrospective cohort, it could not support a firm conclusion.This trial therefore prospectively tests, in patients with persistent atrial fibrillationand an enlarged left atrium undergoing a first rhythm‐control procedure, whetherthoracoscopic ablation is superior to percutaneous catheter ablation.Post‐procedural management is identical in both arms: a 3‐month blanking period,discontinuation of antiarrhythmic drugs at 3 months (up to 6 months) if sinus rhythm ismaintained, and anticoagulation for at least 3 months with subsequent decisions based onrecurrence, prior stroke, and CHA2DS2‐VASc score. Follow‐up visits occur at 3, 6, and 12months and every 6 months thereafter until 1 year after the last patient is enrolled.Rhythm monitoring uses 12‐lead ECG, 24‐hour Holter (3, 6, 12 months), and 14‐day patchmonitoring; echocardiography and NT‐proBNP are obtained at baseline, 12 months, andannually thereafter.