How to ablate long-standing persistent atrial fibrillation?

PURPOSE OF REVIEW: Long-standing persistent (LSP) atrial fibrillation is the most challenging arrhythmia to treat. Catheter ablation of atrial fibrillation has reached satisfactory results for the long-term treatment of paroxysmal atrial fibrillation, but not for the treatment of LSP atrial fibrillation. Several approaches with various outcomes have been described in the literature. The purpose of this review is to summarize the ablation approach that we developed at our institution. RECENT FINDINGS: During ablation of LSP atrial fibrillation, in addition to pulmonary vein antrum and posterior wall isolation, ablation of nonpulmonary vein triggers disclosed by high dosage of isoproterenol seems to be of utmost importance to achieve long-term success after a single procedure. The location of the nonpulmonary vein triggers includes the coronary sinus, the anterior part of the septum, the left atrial appendage and the superior vena cava. Termination of atrial fibrillation during ablation does not seem to influence the outcome. Increasing radiofrequency power from 30 up to 45W seems an important factor to favour durable lesions. SUMMARY: The approach described in this review will guide the reader to what we believe is the best approach for the ablation of patients with LSP atrial fibrillation.