Ensuring long-term arrhythmia freedom: what are the options for long-standing persistent atrial fibrillation?

ABSTRACT Introduction Long-standing persistent atrial fibrillation (LSPAF) is among the most challenging arrhythmia phenotypes to manage, due to extensive atrial remodeling, fibrosis, and the presence of complex non-pulmonary vein substrates and triggers. Conventional antiarrhythmic drug (AAD) therapy provides limited efficacy and is constrained by short- and long-term toxicity. Catheter ablation (CA) remains the cornerstone of rhythm control but offers modest single-procedure success. Areas covered This review examines current treatment strategies for LSPAF, including pharmacologic rhythm control, CA, and hybrid surgical – endocardial approaches. Evidence from major clinical trials and meta-analyses is summarized, highlighting the limitations of pulmonary vein isolation (PVI) as a stand-alone therapy and the role of adjunctive strategies. The article also discusses novel approaches, including pulsed field ablation (PFA), fibrosis-guided mapping, and insights from recent international guidelines. Expert opinion CA remains the most effective rhythm-control strategy for LSPAF, but durable arrhythmia-free survival often requires repeat or hybrid procedures. Hybrid ablation should be considered, particularly in patients with advanced atrial remodeling. Emerging technologies, including PFA, offer the potential for improved outcomes. Future progress will depend on dedicated LSPAF trials with standardized endpoints, long-term follow-up, and broader patient representation to refine selection, optimize lesion sets, and establish the role of next-generation technologies.