All left atrial ablation procedures involve inherent risks. The most common complications are related to vascular access, including hematomas and vascular injury at the femoral site, which are typically manageable with standard care. More serious but less frequent complications include cardiac perforation with tamponade, thromboembolic events such as stroke or TIA, atrio-esophageal fistula, phrenic nerve injury, and air or coronary embolism. For participants randomized to PWI, additional energy delivery on the posterior wall introduces theoretical increased exposure of esophageal and vagus nerve structures, requiring special vigilance. The protocol specifies safety measures including but not limited to intracardiac echocardiography, careful anticoagulation monitoring, esophageal temperature monitoring, power modulation, and phrenic nerve pacing to mitigate these risks. All adverse events are adjudicated independently, with oversight from a Data & Safety Monitoring Board to ensure ongoing participant safety.

While there is no guarantee of direct clinical benefit for any given participant, the trial is designed to capture patient-centered benefits that may result from an optimized ablation strategy. The primary anticipated benefit is reduction in AF symptom burden, measured by validated patient-reported outcomes. Secondary benefits include decreased recurrence of atrial arrhythmia, reduced AF burden on ambulatory monitoring, fewer hospitalizations and emergency visits, and reduced serious clinical events. Patients also receive logistical support such as study-provided 7-day ECG monitoring patches and compensation of $50 for each completed non-procedure study visit. Even if an individual does not experience symptomatic improvement, their participation advances the field by generating much-needed evidence to guide future practice in persistent AF