Limitations
We could only enroll 25 patients from a single hospital in our study,
with a short median duration of follow-up, and therefore larger numbers
of patients enrolled in multiple centers with longer observation times
would have been required to derive statistically rigorous results in
support of the stepwise endo-/epicardial approach for AF CA. All
procedures were performed by expert operators, potentially limiting the
generalizability of our findings. The majority of patients did not have
cardiac implanted devices, which might have led to an underestimation of
subclinical AF recurrences. However, AF/atrial tachycardia recurrences
in a cohort of patients with persistent AF and markedly dilated LA could
expectably present as non-self-limiting episodes, which would likely be
detectable by intermittent rhythm monitoring.