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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]

Background Pulmonary vein isolation (PVI) has emerged as a safe and effective treatment for patients with paroxysmal and persistent atrial fibrillation. Nevertheless, in some patients, a relapse of atrial fibrillation occurs although pulmonary veins are durably isolated. For those patients, the underlying mechanisms of atrial fibrillation perpetuation are manifold and optimal treatment options are not yet defined. Case summary We describe a case of a 55-year-old man with a history of atrial fibrillation and previous PVI presenting with persistent AF and arrhythmia induced cardiomyopathy. During the redo procedure, electro-anatomical mapping revealed durably isolated PV. Bipolar mapping showed large low-voltage areas at the posterior wall and the septum. As the patient was refractory to electrical cardioversion, it was decided to modify the large low-voltage areas as potential arrhythmic substrate. After performing additional ablation with isolation of the posterior wall and two anterior/septal lines, the patient spontaneously converted to sinus rhythm. Discussion Ablation in patients with persistent AF despite durable PVI remains a challenge for the treating team. Individualized ablation approaches addressing additional arrhythmic substrates or extra-PV triggers can be considered to treat patients with persistent AF and durable PVI. [ABSTRACT FROM AUTHOR]

Catheter ablation of atrial fibrillation (AF) is an established therapy that reduces AF burden, improves quality of life, and reduces the risks of cardiovascular outcomes. Although there are clear guidelines for the application of de novo catheter ablation, there is less evidence to guide recommendations for repeat catheter ablation in patients who experience recurrent AF. In this review, we examine the rationale for repeat ablation, mechanisms of recurrence, patient selection, optimal timing, and procedural strategies. We discuss additional important considerations, including treatment of comorbidities and risk factors, risk of complications, and effectiveness. Mechanisms of recurrent AF are often due to non–pulmonary vein (non-PV) triggers; however, there is insufficient evidence supporting the routine use of empiric lesion sets during repeat ablation. The emergence of pulsed field ablation may alter the safety and effectiveness of de novo and repeat ablation. Extrapolation of data from randomized trials of de novo ablation does not optimally inform efficacy in cases of redo ablation. Additional large, randomized controlled trials are needed to address important clinical questions regarding procedural strategies and timing of repeat ablation. [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]

Pulmonary vein isolation (PVI) is the cornerstone in atrial fibrillation (AF) ablation; yet, the role of arrhythmogenic superior vena cava (SVC) is increasingly recognized and different ablation strategies have been employed in this context. SVC can act as a trigger or perpetuator of AF, and its significance might be more pronounced in patients undergoing repeated ablation. Several cohorts have examined efficacy, safety and feasibility of SVC isolation (SVCI) among AF patients. The majority of these studies explored as-needed SVCI during index PVI, and only a minority of them included repeated ablation subjects and non-radiofrequency energy sources. Studies of heterogeneous design and intent have explored both empiric and as-needed SVCI on top of PVI and reported inconclusive results. These studies have largely failed to demonstrate any clinical benefit in terms of arrhythmia recurrence, although safety and feasibility are undisputable. Mixed population demographics, small number of enrollees and short follow-up are the main limitations. Procedural and safety data are comparable between empiric SVCI and as-needed SVCI, and some studies suggested that empiric SVCI might be associated with reduced AF recurrences in paroxysmal AF patients. Currently, no study has compared different ablation energy sources in the setting of SVCI, and no randomized study has addressed as-needed SVCI on top of PVI. Furthermore, data regarding cryoablation are still in their infancy, and regarding SVCI in patients with cardiac devices more safety and feasibility data are needed. PVI non-responders, patients undergoing repeated ablation and patients with long SVC sleeves could be potential candidates for SVCI, especially via an empiric approach. Although many technical aspects remain unsettled, the major question to answer is which clinical phenotype of AF patients might benefit from SVCI? [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]

Pulmonary vein isolation (PVI) is the cornerstone in atrial fibrillation (AF) ablation; yet, the role of arrhythmogenic superior vena cava (SVC) is increasingly recognized and different ablation strategies have been employed in this context. SVC can act as a trigger or perpetuator of AF, and its significance might be more pronounced in patients undergoing repeated ablation. Several cohorts have examined efficacy, safety and feasibility of SVC isolation (SVCI) among AF patients. The majority of these studies explored as-needed SVCI during index PVI, and only a minority of them included repeated ablation subjects and non-radiofrequency energy sources. Studies of heterogeneous design and intent have explored both empiric and as-needed SVCI on top of PVI and reported inconclusive results. These studies have largely failed to demonstrate any clinical benefit in terms of arrhythmia recurrence, although safety and feasibility are undisputable. Mixed population demographics, small number of enrollees and short follow-up are the main limitations. Procedural and safety data are comparable between empiric SVCI and as-needed SVCI, and some studies suggested that empiric SVCI might be associated with reduced AF recurrences in paroxysmal AF patients. Currently, no study has compared different ablation energy sources in the setting of SVCI, and no randomized study has addressed as-needed SVCI on top of PVI. Furthermore, data regarding cryoablation are still in their infancy, and regarding SVCI in patients with cardiac devices more safety and feasibility data are needed. PVI non-responders, patients undergoing repeated ablation and patients with long SVC sleeves could be potential candidates for SVCI, especially via an empiric approach. Although many technical aspects remain unsettled, the major question to answer is which clinical phenotype of AF patients might benefit from SVCI?

Purpose: We examined the characteristics of non-pulmonary vein (PV) triggers in repeat ablation after cryoballoon ablation for paroxysmal atrial fibrillation (PAF).Methods: This study evaluated 119 patients undergoing a second ablation procedure for recurrent atrial tachyarrhythmia (ATA) after cryoballoon PV isolation (CB-PVI) for PAF.Results: Fifty-three of 119 (45%) patients had PV reconnection. All reconnected PVs were isolated. No non-PV triggers were elicited in 42/119 (35%) patients (NNPV group). In 77/119 (65%) patients, 139 isoproterenol-induced non-PV triggers, including 45 triggers that initiated AF, were identified. Non-PV triggers initiating AF were observed at the superior vena cava (SVC), left atrial posterior wall (LAPW) including the PV antra, interatrial septum, right atrium, left atrial appendage/mitral anulus, and coronary sinus in 14 (12%), 10 (8%), 8 (7%), 7 (6%), 4 (3%), and 2 (2%) patients, respectively. Non-PV triggers originated from only the SVC and/or LAPW including the PV antra, and the SVC and/or LAPW was isolated in 18/119 (15%) patients (SVC/LAPW group). Non-PV triggers originating from other sites were focally ablated in 59/119 (50%) patients (OS group). During a median 461 days of follow-up, 39/42 (93%), 17/18 (94%), and 38/59 (64%) patients in the NNPV, SVC/LAPW, and OS groups, respectively, remained ATA recurrence-free. The recurrence rate was higher in the OS group than in the NNPV (P = 0.005) or SVC/LAPW groups (P = 0.042).Conclusions: Over half of patients had non-PV triggers at subsequent ablation after CB-PVI. Non-PV triggers from the SVC/LAPW can be eliminated more successfully than triggers from other sites. [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]

Competing Interests: No conflict of interest for all authors above.

Background. Catheter pulmonary vein isolation (PVI) is the main interventional procedure for treatment of atrial fibrillation (AF). Recurrences of arrhythmia paroxysms in the postoperative period are mainly determined by reconnection of conduction from the pulmonary veins. However, non-pulmonary vein triggers and a positive vagal response of ganglionated plexi (GP) to high frequency stimulation after PVI confirmed by drug testing may affect the long-term efficacy of catheter AF ablation. Aim. To evaluate the efficacy of PVI isolation after drug testing and a negative response to high-frequency stimulation and a positive response to high-frequency stimulation but without subsequent ablation in patients with paroxysmal AF, as well as the efficacy of PVI confirmed by drug testing in patients having nonpulmonary vein triggers. Methods. The present analysis is a part of the randomized study on the comparison of PVI confirmed by drug testing with the absence of non-pulmonary vein triggers and a positive response of GP to high-frequency stimulation with and without GP ablation. PVI was performed in 311 patients. Ninety-six patients were excluded because they required additional GP ablation. Two hundred and fourteen patients were divided into three groups: PVI with a positive GP response (posGP) to high-frequency stimulation without GP ablation (group I, n = 97), PVI with a negative GP response (negGP) to high-frequency stimulation (group II, n = 79) and PVI with non-pulmonary vein triggers (group III, n = 38). The primary endpoint of the study was the freedom from any atrial tachyarrhythmias after 12 months of follow-up confirmed by 24-hour Holter monitoring. The secondary endpoints included the frequency of detecting dormant pulmonary vein conduction, non-pulmonary vein triggers, negative GP response to high-frequency stimulation after catheter PVI. The patients were followed 3, 6, 9, 12 months after the ablation procedure. Results. At the end of the follow-up 57 (72.2%) patients in the PVI + negGP group (group II), 58 (59.8%) patients in the PVI + posGP group (group I) and 20 (52.6%) patients in the PVI + NPT (group III) were free from any atrial tachyarrhythmia (р=0.07; log-rank test). A statistical significance in the efficacy was observed when group II was compared with group III (72.2% and 52.6%, р = 0.028, log-rank test). In the course of primary ablation following PVI, when performing drug testing, dormant atriovenous conduction sites were observed in 105 (33.8%) patients, while non-pulmonary vein triggers (n = 79) were recorded in 38 (12.2%) patients. The frequency of negative GP responses to high-frequency stimulation after PVI accounted for 28.3%. Conclusion. Pulmonary vein isolation confirmed by drug testing, without a response of GP to high-frequency stimulation tends to provide higher efficacy in maintaining the sinus rhythm as compared with PVI and a positive GP response to high-frequency stimulation, but without a statistical significance, whereas nonpulmonary vein triggers after PVI are associated with lower efficacy in the long-term follow-up.

Purpose: Whether or not pulmonary vein isolation (PVI) plus left atrial posterior wall isolation (PWI) using contact force (CF) sensing improves the ablation outcome for persistent atrial fibrillation (AF) is unclear. This study compared the outcome of PVI plus PWI and additional non-PV trigger ablation for persistent AF with/without CF sensing. Methods: This retrospective cohort study analyzed 148 propensity score-matched persistent AF patients (median duration of persistent AF, 8 months (interquartile range, 3–24 months); left atrial diameter, 43 ± 7 mm) undergoing PVI plus PWI and ablation of non-PV triggers provoked by high-dose isoproterenol, including 74 with CF-sensing catheters (CF group) and 74 with conventional catheters (non-CF group). PVI plus PWI with no additional ablation but cavotricuspid isthmus ablation was performed without non-PV triggers in 48 CF patients (65%) and 54 non-CF patients (73%) (P = 0.38). In all other patients, we performed additional ablation of provoked non-PV triggers. Results: The Kaplan-Meier estimate of the rate of freedom from atrial tachyarrhythmia recurrence off antiarrhythmic drugs at 12 months after the single procedure was higher in the CF group than in the non-CF group (85 vs. 70%, log-rank P = 0.030). A multivariable analysis revealed that using CF sensing and non-inducibility of AF from a non-PV trigger after PVI and PWI were significantly associated with a reduced rate of atrial tachyarrhythmia recurrence. Conclusions: Compared with non-CF sensing, PVI plus PWI and additional non-PV trigger ablation using CF-sensing catheters for persistent AF can reduce the rate of atrial tachyarrhythmia 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]

Ablation of non-pulmonary vein (PV) triggers is an important step to improve outcomes in atrial fibrillation ablation. Non-pulmonary vein triggers typically originates from predictable sites (such as the left atrial posterior wall, superior vena cava, coronary sinus, interatrial septum, and crest terminalis), and these areas can be ablated either empirically or after observing significant ectopy (with or without drug challenge). In this review, we will focus on ablation of non-PV triggers, summarizing the existing evidence and our current approach for their mapping and ablation. [ABSTRACT FROM AUTHOR]

Aims: Left atrial (LA) scarring, a consequence of cardiac fibrosis is a powerful predictor of procedure-outcome in atrial fibrillation (AF) patients undergoing catheter ablation. We sought to compare the long-term outcome in patients with paroxysmal AF (PAF) and severe LA scarring identified by 3D mapping, undergoing pulmonary vein isolation (PVAI) only or PVAI and the entire scar areas (scar homogenization) or PVAI+ ablation of the non-PV triggers.Methods and Results: Totally, 177 consecutive patients with PAF and severe LA scarring were included. Patients underwent PVAI only (n = 45, Group 1), PVAI+ scar homogenization (n = 66, Group 2) or PVAI+ ablation of non-PV triggers (n = 66, Group 3) based on operator's choice. Baseline characteristics were similar across the groups. After first procedure, all patients were followed-up for a minimum of 2 years. The success rate at the end of the follow-up was 18% (8 pts), 21% (14 pts), and 61% (40 pts) in Groups 1, 2, and 3, respectively. Cumulative probability of AF-free survival was significantly higher in Group 3 (overall log-rank P <0.01, pairwise comparison 1 vs. 3 and 2 vs. 3 P < 0.01). During repeat procedures, non-PV triggers were ablated in all. After average 1.5 procedures, the success rates were 28 (62%), 41 (62%), and 56 (85%) in Groups 1, 2, and 3, respectively (log-rank P< 0.001).Conclusions: In patients with PAF and severe LA scarring, PVAI+ ablation of non-PV triggers is associated with significantly better long-term outcome than PVAI alone or PVAI+ scar homogenization. [ABSTRACT FROM AUTHOR]

The end point of current catheter-based ablation approaches for the treatment of atrial fibrillation (AF) is the elimination of all the possible triggers with the least amount of ablation necessary. Once all the triggers have been eliminated, the incremental value of any additional lesion sets remains to be proven. Pulmonary vein (PV) isolation is the cornerstone of catheter ablation approaches for eliminating AF triggers. However, up to 11% of patients demonstrate reproducible sustained AF initiation from non-PV foci. In these patients, triggers can typically be elicited using standardized induction protocols, which include cardioversion of spontaneous and/or induced AF and infusion of high-dose isoproterenol. Non-PV triggers typically arise from discrete anatomical structures that include the mitral and tricuspid periannular regions, the crista terminalis and Eustachian ridge, the interatrial septum, the left atrial (LA) posterior wall, the left atrial appendage (LAA), and other thoracic veins such as the superior vena cava, the coronary sinus, and the ligament of Marshall. Localization of non-PV foci involves a detailed analysis of specific intra-atrial activation sequences using multipolar catheters in standard atrial locations coupled with information from the surface electrocardiogram P wave when possible. Multipolar catheters positioned along the coronary sinus and crista terminalis/superior vena cava region together with direct recordings from the right and left PVs allow a quick localization of non-PV foci. Elimination of non-PV triggers by means of focal ablation at the site of origin or isolation of arrhythmogenic structures (eg, LA posterior wall or superior vena cava) has been associated with improved arrhythmia-free survival. [ABSTRACT FROM AUTHOR]

Aims: We evaluated the efficacy of an ablation strategy empirically targeting pulmonary veins (PVs) and posterior wall (PW) and the prevalence and clinical impact of extrapulmonary trigger inducibility and ablation in a large cohort of patients with persistent atrial fibrillation (PerAF)., Methods and Results: A total of 1803 PerAF patients were prospectively enrolled. All patients underwent pulmonary vein antrum isolation (PVAI) extended to the entire PW. A standardized protocol was performed to confirm persistent PVAI and elicit any triggers originating from non-PV sites. All non-PV triggers initiating sustained atrial tachyarrhythmias were ablated. Ablation of non-PV sites triggering non-sustained runs (<30 s) of atrial tachyarrhythmias or promoting frequent premature atrial complexes (≥10/min) was left to operator's discretion. Overall, 1319 (73.2%) patients had documented triggers from non-PV areas. After 17.4 ± 8.5 months of follow-up, the cumulative freedom from atrial tachyarrhythmias among patients without inducible non-PV triggers (n = 484) was 70.2%. Patients with ablation of induced non-PV triggers had a significantly higher arrhythmia control than those whose triggers were not ablated (67.9% vs. 39.4%, respectively; P < 0.001). After adjusting for clinically relevant variables, patients in whom non-PV triggers were documented but not ablated had an increased risk of arrhythmia relapse (hazard ratio: 2.39; 95% confidence interval: 2.01-2.83; P < 0.001)., Conclusion: Pulmonary vein antrum isolation extended to the entire PW might provide acceptable long-term arrhythmia-free survival in PerAF patients without inducible non-PV triggers. In our population of PerAF patients, non-PV triggers could be elicited in ∼70% of PerAF patients and their elimination significantly improved outcomes., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Aims: Left atrial (LA) scarring, a consequence of cardiac fibrosis is a powerful predictor of procedure-outcome in atrial fibrillation (AF) patients undergoing catheter ablation. We sought to compare the long-term outcome in patients with paroxysmal AF (PAF) and severe LA scarring identified by 3D mapping, undergoing pulmonary vein isolation (PVAI) only or PVAI and the entire scar areas (scar homogenization) or PVAI+ ablation of the non-PV triggers., Methods and Results: Totally, 177 consecutive patients with PAF and severe LA scarring were included. Patients underwent PVAI only (n = 45, Group 1), PVAI+ scar homogenization (n = 66, Group 2) or PVAI+ ablation of non-PV triggers (n = 66, Group 3) based on operator's choice. Baseline characteristics were similar across the groups. After first procedure, all patients were followed-up for a minimum of 2 years. The success rate at the end of the follow-up was 18% (8 pts), 21% (14 pts), and 61% (40 pts) in Groups 1, 2, and 3, respectively. Cumulative probability of AF-free survival was significantly higher in Group 3 (overall log-rank P <0.01, pairwise comparison 1 vs. 3 and 2 vs. 3 P < 0.01). During repeat procedures, non-PV triggers were ablated in all. After average 1.5 procedures, the success rates were 28 (62%), 41 (62%), and 56 (85%) in Groups 1, 2, and 3, respectively (log-rank P< 0.001)., Conclusions: In patients with PAF and severe LA scarring, PVAI+ ablation of non-PV triggers is associated with significantly better long-term outcome than PVAI alone or PVAI+ scar homogenization., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For Permissions, please email: journals.permissions@oup.com.)