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Despite advances in ablative therapies, outcomes remain less favorable for persistent atrial fibrillation often due to presence of non-pulmonary vein triggers and abnormal atrial substrates. This review highlights advances in ablation technologies and notable scientific literature on clinical outcomes associated with pursuing adjunctive ablation targets and substrate modification during persistent atrial fibrillation ablation, while also highlighting notable future directions. [ABSTRACT FROM AUTHOR]

Introduction: Earlier studies have shown a clear association between severity of human immunodeficiency virus (HIV) infection and incident atrial fibrillation (AF). We present the long‐term outcome of catheter ablation (CA) and electrophysiological characteristics in HIV+ AF patients. Methods: This study evaluated 1438 consecutive AF patients [31 (2.15%) with HIV and 1407 (97.8%) without HIV diagnosis] undergoing their first CA at our center. A total of 31 HIV patients and 31 controls were generated by propensity matching, based on calculated risk factor scores, using a logistic model. During first procedure, all received isolation of pulmonary vein (PV) + posterior wall and superior vena cava. Non‐PV triggers, defined as ectopic triggers originating from sites other than PVs, were identified at the redo ablation with high‐dose isoproterenol challenge. Results: Clinical characteristics were not different between the groups. When compared to the control, by the end of 5 years after the first procedure, recurrence was significantly greater in HIV group [100% vs. 54%, p <.001]. Among patients that underwent redo ablation non‐PV triggers were higher in HIV group [93.5% vs. 54%, p <.001], and most frequently originated from the coronary sinus [67.7% vs. 45.2%, p <.001] and left atrial appendage [41.9% vs. 25.8%, p <.001]. After focal ablation of non‐PV trigger, no difference in arrhythmia recurrence between two groups [80.6% vs. 87.1%, p =.753] at 1‐year follow up was found. Conclusion: Our findings suggest that non‐PV triggers are highly prevalent in HIV+ AF patients resulting in higher rate of the mid‐ and long‐term arrhythmia recurrence. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate the difference in effectiveness and safety of high-power, short-duration (HPSD) radiofrequency catheter ablation (RFA) guided by relatively low ablation index (AI) values and conventional RFA in paroxysmal atrial fibrillation (PAF) patients. Methods: The HPSD RFA strategy (40–50 W, AI 350–400 for anterior, 320–350 for posterior wall; n = 547) was compared with the conventional RFA strategy (25–40 W, without AI; n = 396) in PAF patients who underwent their first ablation. Propensity-score matching analyses were used to compare the outcomes of the two groups while controlling for confounders. Results: After using propensity-score matching analysis, the HPSD group showed a higher early recurrence rate (22.727% vs. 13.636%, p = 0.003), similar late recurrence rate, and comparable safety (p = 0.604) compared with the conventional group. For late recurrent atrial arrhythmia types, the rate of regular atrial tachycardia was significantly higher in the HPSD group (p = 0.013). Additionally, the rate of chronic pulmonary vein reconnection and non-pulmonary vein triggers during repeat procedures was similar in both groups. Conclusions: For PAF patients, compared with the conventional RFA strategy, the HPSD RFA strategy at relatively low AI settings had a higher early recurrence rate, similar long-term success rate, and comparable safety. [ABSTRACT FROM AUTHOR]

Introduction: Non‐pulmonary vein (PV) triggers are a major cause of atrial tachyarrhythmia (ATA) recurrence after catheter ablation. However, the effect of the diagnosis‐to‐ablation time (DAT) on non‐PV triggers in persistent atrial fibrillation is unknown. Methods and Results: This observational study evaluated 502 consecutive persistent AF patients who underwent initial ablation. We compared 408 patients whose DAT was <3 years with 94 patients whose DAT was ≥3 years. Following PV and posterior wall isolation, 193 non‐PV triggers, including 50 AFs, 30 atrial tachycardias (ATs), and 113 repetitive atrial premature beats, were elicited and ablated in 137 (27%) patients. Specifically, 80 non‐PV AF/AT triggers were provoked in 64 (13%) patients, being identified more frequently in the DAT ≥ 3 years group than in the DAT < 3 years group (20% vs. 11%, p =.025) especially with a higher prevalence of coronary sinus/inferior left atrial triggers. During a median follow‐up of 770 days, the ATA recurrence‐free rate was higher in the DAT < 3 years group than the DAT ≥ 3 years group (79% vs. 53% at 2 years, p <.001). In a multivariate analysis, female sex (odds ratio: 2.70, p =.002) and a longer DAT (odds ratio: 1.13/year, p =.008) were predictors of non‐PV AF/AT triggers, and a longer DAT (hazard ratio: 1.12/year, p <.001) and non‐PV AT/AF triggers (hazard ratio: 1.79, p =.009) were associated with ATA recurrence. Conclusion: Early ablation after the first diagnosis of persistent AF may reduce emerging non‐PV AF/AT triggers and ATA recurrence. [ABSTRACT FROM AUTHOR]

A case study of a 67‐year‐old woman with recurrent persistent atrial fibrillation (AF) and having undergone pulmonary vein isolation (PVI) is presented. Topics discussed include normal left ventricular systolic function with mild to moderate left atrial enlargement; and advent of force‐sensing catheters, high‐frequency low‐volume ventilation, and long sheaths resulting in more effective persistent PVI, the situation has become increasingly common in clinical practice.

Introduction: Outcome data after catheter ablation (CA) for longstanding persistent atrial fibrillation (LSPAF) lasting less than 2 years are limited and highly variable with different ablation approaches. We aimed to assess the long‐term outcomes in patients with LSPAF lasting less than 2 years undergoing extended pulmonary vein antrum isolation (PVAI) versus those with additional non‐pulmonary vein (PV) trigger ablation. Methods and Results: In this prospective analysis, 381 consecutive patients with LSPAF lasting less than 2 years (age: 64 ± 9 years, 76% male, atrial fibrillation duration: 19 ± 5 months) undergoing their first CA were classified into two groups: Group 1 (n = 104) received PVAI extended to PW plus isolation of superior vena cava (SVC) and Group 2 (n = 277) received PVAI + PW + SVC + non‐PV–trigger ablation. All patients were followed‐up for at least 2 years. In case of recurrence, repeat procedure was offered and non‐PV triggers were targeted for ablation in all. After a single procedure, 26 (25%) patients in Group 1 and 172 (62.1%) in Group 2 remained arrhythmia‐free (P < 0.001). A second procedure was performed in 58 of 78 (74.4%) patients in Group 1 and 77 of 105 (73.3%) patients in Group 2. Non‐PV triggers were identified in 52 (89.6%) and 54 (70.1%) patients in Groups 1 and 2, respectively, and targeted for ablation. Overall, 72 (69.2%) patients in Group 1 and 238 (86%) in Group 2 remained arrhythmia‐free (P < 0.001). Conclusion: In patients with LSPAF lasting less than 2 years, extended PVAI plus SVC isolation was less likely to achieve long‐term sinus rhythm. In the majority of patients, recurrence was due to non‐PV triggers and ablation of those resulted in better outcome. [ABSTRACT FROM AUTHOR]