Persistent Atrial Fibrillation Ablation: Ongoing Challenges Defining the Target Population and Substrate

Abstract Purpose of Review Catheter ablation (CA) is a well-established treatment for paroxysmal atrial fibrillation (AF), but outcomes in persistent AF can be suboptimal. This review summarises recent evidence relating to the ideal patient population and target substrate for CA, and the techniques available. Recent Findings Risk scores can identify individuals with persistent AF who are more likely to benefit from CA. Pulmonary vein isolation (PVI) remains the most important ablation technique but non-pulmonary vein triggers explain the high recurrence rates in persistent AF. Novel electroanatomic mapping technologies, hybrid approaches, ethanol vein of Marshall ablation and thoracoscopic epicardial ablation are promising recent developments. Pulsed field ablation (PFA) is a new ablation modality with an excellent safety profile in trials to date; its role in persistent AF remains an area of study. Summary Improving outcomes of CA in persistent AF remains a significant research focus, with several encouraging directions for future study.