Combined Endoscopic Epicardial and Percutaneous Endocardial Ablation Versus Repeated Catheter Ablation in Persistent and Longstanding Persistent Atrial Fibrillation

Inclusion criteria

• Patient has a history of symptomatic Persistent AF and a left atrium (LA) > 4cm or Long Standing Persistent AF as defined by the HRS/EHRA/ECAS expert consensus statement
• Patient is refractory to or intolerant of at least one antiarrhythmic drug (class I or III)
• Patient is mentally able and willing to give informed consent

Exclusion criteria

• Patient has longstanding persistent AF > 10 years
• Patient presenting with paroxysmal AF
• Patient with persistent AF and a LA-diameter ≤ 4cm
• AF is secondary to electrolyte imbalance, thyroid disease, or other reversible or non-cardiovascular cause
• Patient underwent previous ablation procedure or heart surgery
• Patient needs other cardiac surgery procedures besides AF treatment (valve, coronary, others)
• Contraindication for either catheter ablation or epicardial surgery (including, but not limited to: previous thoracic radiation, previous perimyocarditis, Previous cardiac tamponade, Pleural adhesions, Prior thoracotomy)
• Body mass index > 35
• LA Diameter > 6 cm
• Left ventricular ejection fraction < 30 %
• Severe mitral regurgitation (>II)
• Patient unable to undergo TransEsophageal Echocardiogram (TEE)
• Presence of LA thrombus by TEE, CT scan, MRI or angiography
• History of cerebrovascular disease, including stroke or transient ischemic attack (TIA) within 6 months prior to enrollment
• Active infection or sepsis
• Other clinical conditions precluding inclusion (e.g., organ disease, disturbances of hemostasis)
• Contraindication to anticoagulant therapy, or inability to comply with anticoagulant therapy
• Pregnancy, planned pregnancy or breastfeeding
• Life expectancy is less than 12 months
• Patient is involved in another study involving an investigational drug or device