Contemporary Outcomes of Catheter Ablation of Long‐Standing Persistent Atrial Fibrillation

Background Advances in mapping and ablation have improved the safety and efficacy of catheter‐based ablation (CA) of atrial fibrillation (AF). Patients with long‐standing persistent atrial fibrillation (LSPAF) historically have poor ablation outcomes; however, they are underrepresented in contemporary reports. Objective To evaluate ablation approaches and long‐term rhythm control following contemporary catheter ablation for LSPAF. Methods A single‐center, retrospective analysis of patients undergoing CA for LSPAF between 2021 and 2025 was performed. Demographic and procedural characteristics were analyzed; 1‐year arrhythmia free survival and atrial arrhythmia burden were assessed. Results Ninety‐five patients (median age 68 years [IQR, 63–73]; 80% male; median BMI 32.4 kg/m 2 [IQR, 28.6–35.6]; median ejection fraction 55% [IQR, 49%–60%]; 37% with prior CA) were followed for a median of 20.2 months (IQR, 10.2–29.7). Radiofrequency ablation alone was used in 74 patients (78%), pulsed‐field ablation alone in 13 (14%), and both in 8 (8%). Pulmonary veins were isolated in all patients, 88 (93%) underwent additional left atrial ablation, including linear ablation in 88 (93%), posterior wall isolation or ablation in 72 (76%), vein of Marshall ethanol infusion or ablation in 25 (26%), coronary sinus ablation in 24 (25%), and cavotricuspid isthmus ablation in 23 (24%). Fourteen of 92 post‐blanking evaluable patients (15.2%) were receiving a class I or III antiarrhythmic drug at last follow‐up. Among 57 patients with adequate post‐blanking follow‐up after a first AF ablation (of 60 first‐ablation patients overall), 1‐year arrhythmia‐free survival was 39.3% (95% CI, 27.8%–55.4%). Among all patients and after allowing repeat procedures, 1‐year arrhythmia‐free survival was 53.5% (95% CI, 43.3%–66.1%). Among patients with continuous monitoring, median arrhythmia burden decreased from 90.1% (IQR, 21.1%–99.4%) before ablation to 0.0% (IQR, 0.0%–3.8%) at 6 months and 0.0% (IQR, 0.0%–20.0%) at 12 months. Conclusion In this contemporary cohort of patients undergoing CA for LSPAF, 1‐year arrhythmia‐free survival was 53.5% when repeat procedures were allowed. Among patients with implanted cardiac devices, arrhythmia burden was markedly reduced after ablation and may complement conventional time‐to‐first‐recurrence endpoints.