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Objectives  This study aimed to assess the comparative efficacy of four ablation strategies on the incidence rates of freedom from atrial fibrillation (AF) or atrial tachycardia (AT) through a 3‐year follow‐up in patients with persistent AF.    Background  The optimal substrate modification strategies using catheter ablation for patients with persistent AF remain unclear.    Methods  Patients with persistent AF were enrolled consecutively to undergo each of four ablation strategies: (a) Group 1 (Gp 1,  n  = 69), pulmonary vein isolation (PVI) plus rotor ablation assisted by similarity index and phase mapping; (b) Gp 2 ( n  = 75), PVI plus linear ablations at the left atrium; (c) Gp 3 ( n  = 42), PVI plus the elimination of complex fractionated atrial electrograms; (d) Gp 4 ( n  = 67), PVI only. Potential confounders were adjusted via a multivariate survival parametric model.    Results  Baseline characteristics were similar across the four groups. At a follow‐up period of 34.9 ± 38.6 months, patients in Gp 1 showed the highest rate of freedom from AF compared with the other three groups ( p  = .002), while patients in Gp 3 and 4 showed lower rates of freedom from AT than those of the other two groups ( p  = .006). Independent predictors of recurrence of AF were the ablation strategy ( p  = .002) and left atrial diameter (LAD) ( p  = .01).    Conclusion  In patients with persistent AF, a substrate modification strategy using rotor ablation assisted by similarity index and phase mapping provided a benefit for maintaining sinus rhythm compared with the other strategies. Both ablation strategy and baseline LAD predicted the 3‐year outcomes of freedom from AT/AF

Optimal substrate modification strategies using catheter ablation in patients with persistent atrial fibrillation: 3‐year follow‐up outcomes