Commentary on “Thoracoscopic surgical ablation for atrial fibrillation patients with functional regurgitation: the treatment strategy prioritizing atrial fibrillation”

Dear Editor, We read with great interest the recent publication titled “Thoracoscopic surgical ablation for atrial fibrillation patients with functional regurgitation: the treatment strategy prioritizing atrial fibrillation” by Sun et al1, which investigates the interactions between thoracoscopic surgical ablation (TSA) and functional regurgitation (FR) in patients with atrial fibrillation (AF). Furthermore, it explores the feasibility of a treatment strategy that prioritizes AF to manage FR. This study presents findings that are suggestive of the potential of TSA to reduce FR and improve cardiac function; however, it is important to note that several concerns and limitations need to be addressed in order to strengthen the reliability and applicability of the study’s conclusions. We have been assured that the article complies with TITAN Guidelines 2025—governing the declaration and use of artificial intelligence2. First, while the study encompasses a total of 152 patients, the subgroup analysis, particularly for patients with both functional mitral regurgitation and functional tricuspid regurgitation, is relatively small. This may result in a limitation of the statistical power of the findings for these subgroups, with the potential for Type II errors, leading to the undetection of significant differences. The restricted sample size for specific subgroups has been demonstrated to impact the generalizability of conclusions, particularly in cases involving more complex patient populations or rarer complications that may not be adequately represented in the study cohort3. Second, although the 12-month follow-up period yielded valuable short- to mid-term data, it may be insufficient to fully evaluate the long-term outcomes of TSA on FR and cardiac remodeling. The investigation did not extend to the exploration of long-term complications, including the progression of AF, the recurrence of AF, and the necessity for re-interventions. These are significant factors to be taken into consideration when evaluating the overall success and sustainability of TSA as a treatment strategy for AF patients with FR. Third, the study primarily focuses on patients with mild to moderate FR, which may limit the external validity of the findings for patients with severe FR. While the cohort with mild to moderate FR is useful for understanding the effects of TSA in this specific population, the inclusion of patients with severe FR would be important to assess the universal applicability of the results. It is acknowledged that varying degrees of FR may have a bearing on the results of the procedure. Furthermore, it is recognized that the study’s findings may not be directly applicable to patients with more severe forms of FR4. Moreover, the study was conducted at a single center, which may limit the external validity of the results. The outcomes of the procedure may be influenced by a variety of factors, including the expertise of the medical facility, the demographics of the patient population, and the quality of the healthcare infrastructure. A multicenter trial would engender greater diversity within the patient population, thereby enhancing the generalizability of the findings across a range of settings. This approach would serve to mitigate the likelihood of bias, thereby enhancing the reliability of the study’s conclusions. Furthermore, while the authors provide a comprehensive analysis of the changes in FR degrees and cardiac function after TSA, they do not provide a detailed analysis of the potential risks and complications associated with the procedure. It is imperative to consider the possibility of other potential complications, including but not limited to infections, bleeding, or procedural failures, that may occur in the postoperative period. A more thorough reporting and analysis of all complications would offer a clearer understanding of the risks associated with TSA5. In conclusion, while the study by Sun et al offers valuable insights into the potential of TSA to reduce FR and improve cardiac function in AF patients, there are several limitations that need to be addressed in future studies. These include a limited sample size for certain subgroups, a relatively short follow-up period, limited patient demographics, lack of multicenter validation, and incomplete reporting of complications. It is recommended that future research endeavors focus on addressing the aforementioned concerns, with the objective of providing a more robust and comprehensive understanding of the long-term benefits and risks of TSA in AF patients with FR.