Current strategies for non‐pharmacological therapy of long‐standing persistent atrial fibrillation

Non‐pharmacological rhythm control of atrial fibrillation (AF) is becoming increasingly important in our aging society. Advancement of catheter ablation techniques in the last decade has provided a cure for AF patients, with a nearly established efficiency for paroxysmal cases. However, since ablation of persistent/chronic AF cases is still challenging, early treatment of paroxysmal AF before transformation to the persistent/chronic form is mandatory. Although there is a consensus that pulmonary vein isolation is the first‐line approach for ablation of long‐standing persistent AF, similar to that for paroxysmal AF, there are still wide variations in the adjunctive approach to modify the atrial substrate of persistent AF (anatomical linear ablation, electrogram‐based complex fractionated atrial electrogram ablation, ganglionated plexus ablation, etc.). Since data comparing the effectiveness of these adjunctive approaches are still lacking, large‐scale controlled trials evaluating the effect of catheter ablation in diverse patient populations on a long‐term basis are needed to establish the appropriate approach for long‐standing persistent AF. Furthermore, the development of de novo ablation methods (new energies, new targets, etc.) is expected to improve ablation outcome in patients with long‐standing persistent AF.