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BackgroundAtrial fibrillation (AF) is the most common arrhythmia of clinical significance. Pulmonary vein isolation (PVI) is the cornerstone for ablation treatment of AF. In a significant number of patients with AF and specially patients with persistent AF, only PVI is not sufficient to achieve arrhythmia freedom. Several studies have shown that fibrosis in the left atrium is unfavorable and that fibrosis contribute to initiation and maintenance of AF.Purpose and AimThis study aims to investigate whether box isolation of fibrotic areas (BIFA) as an adjunct to PVI increases the rate of arrhythmia freedom and improves quality of life in patients with persistent AF. Study design206 patients with persistent AF and left atrial fibrosis are randomized, either to standard PVI or to PVI + BIFA. another 103 patients with persistent AF but without left atrial fibrosis receives only standard PVI treatment. All 309 patients are followed up for 2 years for recurrence of arrythmia and quality of life. Our aim is to recruit all patients among Karolinska, Linköping, Umeå and Sahlgrenska university hospital within 2 to 3 years.MeaningRandomized controlled studies are needed to evaluate the results of new ablation strategies. If we find that PVI + BIFA gives better success rates without increasing the risk of complications, more patients should have access to this treatment. If we find the opposite, then a re-evaluation should be done if this additional treatment should be carried out.