Concomitant atrial fibrillation surgery for people undergoing cardiac surgery

Epicardial and endocardial surgical ablation of atrial fibrillation: outcomes from CASE-AF Registry

OBJECTIVES

The German CArdioSurgEry Atrial Fibrillation Registry is a prospective, multicentric registry analysing outcomes of patients undergoing surgical ablation for atrial fibrillation as concomitant or stand-alone procedures. This data sub-analysis of the German CArdioSurgEry Atrial Fibrillation Registry aims to describe the in-hospital and 1-year outcomes after concomitant surgical ablation, based on 2 different ablation approaches, epicardial and endocardial surgical ablation.

METHODS

Between January 2017 and April 2020, 17 German cardiosurgical units enrolled 763 consecutive patients after concomitant surgical ablation. In the epicardial group, 413 patients (54.1%), 95.6% underwent radiofrequency ablation. In the endocardial group, 350 patients (45.9%), 97.7% underwent cryoablation. 61.5% of patients in the epicardial group and 49.4% of patients in the endocardial group presenting with paroxysmal atrial fibrillation. Pre-, intra- and post-operative data were gathered.

RESULTS

Upon discharge, 32.3% (n = 109) of patients after epicardial surgical ablation and 24.0% (n = 72) of patients after endocardial surgical ablation showed recurrence of atrial fibrillation. The in-hospital mortality rate was low, 2.2% (n = 9) in the epicardial and 2.9% (n = 10) in the endocardial group. The overall 1-year procedural success rate was 58.4% in the epicardial and 62.2% in the endocardial group, with significant symptom improvement in both groups. The 1-year mortality rate was 7.7% (n = 30) in epicardial and 5.0% (n = 17) in the endocardial group.

CONCLUSIONS

Concomitant surgical ablation is safe and effective with significant improvement in patient symptoms and freedom from atrial fibrillation. Adequate cardiac rhythm monitoring should be prioritized for higher quality data acquisition.

Atrial fibrillation ablation during robotic mitral valve surgery: a systematic review and meta-analysis

Background

Atrial fibrillation (AF) is the most common arrhythmia, and is also associated with mitral valve disease. Although the benefits of robotic mitral valve surgery are well documented, literature combining robotic mitral valve surgery with AF surgery remains sparse. The aim of this systematic review and meta-analysis is to evaluate the evidence assessing the efficacy and safety of AF ablation during robotic mitral valve surgery.

Methods

Five electronic databases were searched from inception to April 2023. All studies reporting the primary outcome, freedom from AF, for patients with a history of AF undergoing robotic mitral valve surgery and AF ablation were identified. Studies which included mixed cohorts, or patients who did not undergo robotic mitral valve surgery were excluded. Relevant data were extracted and a meta-analysis of proportions was conducted using a random-effects model.

Results

Five studies were included with a total of 241 patients. Cohort sizes ranged from 11 to 94 patients. The aggregate mean age was 58.5 years and patients had persistent AF (71.1%). All five studies utilised the da Vinci® Surgical System, and performed variable lesion sets. The freedom from AF was 88.1% at a weighted mean follow-up of 6.9 months. There were two mortalities (0.8%), two patients required conversion to sternotomy (1.4%) and eight required a permanent pacemaker (3.7%).

Conclusions

AF ablation with robotic mitral valve surgery can be performed with adequate short-term efficacy and safety profile. Current evidence on AF ablation and robotic mitral valve surgery is limited to low-quality retrospective data with inherent selection bias. Further large-scale prospective data is required to verify these results.

Surgical ablation of atrial fibrillation during mitral valve surgery: a systematic review and meta-analysis

Background

Atrial fibrillation (AF) is a common tachyarrhythmia, affecting approximately 33 million people worldwide, and is frequently associated with mitral valve disease. Surgical ablation during mitral valve surgery provides an opportune circumstance for arrhythmia correction. The results of recent randomized trial data are promising, demonstrating both safety and efficacy. The aim of this systematic review is to report the efficacy and morbidity of concomitant surgical ablation for AF during mitral valve surgery.

Methods

Five electronic databases were searched from inception to March 2023. All studies reporting the primary outcome, freedom from AF (FFAF), for patients with a history of AF undergoing concomitant mitral valve surgery were identified. Studies with patient cohorts less than 100 were excluded. Relevant data were extracted and a meta-analysis of proportions was conducted using a random-effects model. Survival data were pooled from original Kaplan-Meier curves and reconstructed, reporting aggregate FFAF and survival.

Results

Thirty-six studies with a total of 8,340 patients were included in the systematic review. All 36 papers reported postoperative FFAF with a pooled result of 76.9% [95% confidence interval (CI): 73.8-79.9%] at a weighted mean follow-up of 40.2 months, however this result was associated with significant heterogeneity (I2=89%). A total of 31 studies reported postoperative short-term mortality, with a pooled result of 1.68% (95% CI: 1.15-2.29%). Aggregate survival at 1 to 5 years was 93.7%, 92.5%, 91.3%, 89.4%, and 87%, respectively, and aggregate FFAF for 1 to 5 years was 90.2%, 83.5%, 79.5%, 76.4% and 73.2%, respectively.

Conclusions

Evaluation of the evidence suggests that concomitant ablation for AF during mitral valve surgery is both safe and efficacious. The results were associated with significant heterogeneity, reflective of variable institutional protocols, patient characteristics, and lesion sets. Randomized data with longer term follow-up would help validate these results.

Case Report: Giant Congenital Left Atrial Appendage Aneurysm Presenting With Acute Massive Cerebral Infarction and Refractory Atrial Fibrillation: A Case Report and Literature Review

Background

Congenital left atrial appendage aneurysm (LAAA) is a rare cardiac anomaly with a variety of presentations, from being asymptomatic to potentially serious complications such as systemic thromboembolism and atrial tachyarrhythmia.

Case Presentation

We report a case of congenital giant LAAA in a 35-year-old man presenting with acute massive cerebral infarction and atrial fibrillation (AF) with rapid ventricular rate. The AF was refractory to conventional antiarrhythmic agents, such as amiodarone and electrical cardioversion, but restored and maintained sinus rhythm after surgical resection of LAAA. The patient remained free of events and was in sinus rhythm during half-year follow-up.

Conclusion

Giant LAAA has the potential causing serious complications and should be managed surgically in most cases.

Evaluating the cost-effectiveness of catheter ablation of atrial fibrillation

Background

The pursuit of a clearer understanding of the pathogenesis of atrial fibrillation (AFib) and the development of new technology has resulted in a surge of interest in the surgical ablation for AFib. Here, we report our 8-year experience in the surgical treatment and management of AFib alongside, evaluating the cost-effectiveness in southern Mainland China over a 1-year follow-up.

Methods

Data of 3,068 patients from March 2011 through June 2019 was retrospectively extracted from The Provincial National Cardiac Database of Xiangya Second Hospital. The activities considered (and costs calculated) were outpatient consultations, hospital admissions, and drug treatment. Quality of life (QoL) questionnaires were also carried out to assess whether concomitant AFib correction procedures increase risk in patients, or improve patient's QoL.

Results

A total of 3,068 patients completed the questionnaires at a minimum of one time-point during the follow-up. The total cost was combined to obtain incremental costs per quality-adjusted life-years (QALYs). The total costs of the AFib catheter ablation group were remarkably higher compared to surgery as usual group. The incremental cost-effectiveness ratio was $76,513,227 (¥542,287,667) per QALY, with an acceptability line graph for cost at 43%.

Conclusions

AFib is an extraordinarily costly and worrisome public health problem. Precision medicine is vital as it provides a platform for the clinical translation of targeted interventions that are designed to help treat and prevent AFib. Thus, to improve the QoL expectancy outcome(s), both therapeutic and surgical interventions should be aimed at addressing the underlying heart disease rather than restoring sinus rhythm.

Left atrial appendage aneurysm: A case report

BACKGROUND

An aneurysm of the left atrial appendage is one of the rare but potentially hazardous heart defects. The risk of lethal complications grows with its size. To date, about 150 cases of this defect have been described in the literature. We present a case of left atrial appendage aneurysm with the deformation of the mitral valve and the left main coronary and circumflex artery, which required mitral valve annuloplasty and bifurcation stenting.

CASE SUMMARY

A 58-year-old man presented to our hospital complaining of shortness of breath, general weakness, dizziness during physical exertion, and fatigue. Based on the results of echocardiography, an aneurysm of the left atrium was suspected. A free-breathing real-time cine magnetic resonance imaging with electrocardiograph synchronization confirmed the diagnosis of left atrial appendage aneurysm. The patient underwent an aneurysmectomy via a median sternotomy with cardiopulmonary bypass. Intraoperative transesophageal echocardiography revealed relative mitral insufficiency that was corrected with an annuloplasty ring. Intraoperative coronary angiogram showed impaired blood flow in the left main coronary and circumflex artery and 60% stenosis. For this reason, bifurcation stenting was performed. The patient had an uneventful postoperative clinical course and was discharged from the hospital on the 10th day in a satisfactory condition.

CONCLUSION

Left atrial appendage aneurysm is a rare and dangerous heart pathology that requires surgery to prevent related complications.

Partial upper sternotomy for concomitant left atrial ablation and aortic valve replacement

BACKGROUND

Minimally invasive access via partial sternotomy has been established for aortic valve surgery in the past years. But concomitant procedures like atrial ablation and aortic valve replacement via partial upper sternotomy have not been investigated so far. We therefore present our operative technique and results in terms of safety and efficacy, including follow-up and quality of life.

METHODS

Between February 2007 and March 2014 a total of 67 patients undergoing isolated minimally invasive aortic valve replacement received concomitant left atrial ablation at our centre. Operative technique and short- and midterm results are described, including quality of life assessment using the SF-36 questionnaire.

RESULTS

Operative techniqual success rate was 98.5%. We observed only one (1.5%) ablation-related conversion to full sternotomy. Operative times, reexploration and stroke rates as well as 30-day mortality are comparable to open procedures. Efficacy: The proportions of patients in sinus rhythm at discharge was 54.5% for paroxysmal AF patients and 27.7% overall. After a mean follow-up time of 38.0±22.6 months the cardiac related mortality rate was 4.5%, the rate of sinus rhythm was 72.7% for paroxysmal AF patients and 36.8% overall. Of survivors, overall mean quality of life was 7.3±2.1 as measured by SF-36.

CONCLUSIONS

Concomitant left atrial ablation and aortic valve replacement can safely be performed via partial sternotomy and results are non-inferior to open surgery.

Socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions: a systematic review of peer-reviewed literature, 1990-2018

BACKGROUND

Hospitalizations for chronic ambulatory care sensitive conditions are an important indicator of health system equity and performance. Chronic ambulatory care sensitive conditions refer to chronic diseases that can be managed in primary care settings, including angina, asthma, and diabetes, with hospitalizations for these conditions considered potentially avoidable with adequate primary care interventions. Socioeconomic inequities in the risk of hospitalization have been observed in several health systems globally. While there are multiple studies examining the association between socioeconomic status and hospitalizations for chronic ambulatory care sensitive conditions, these studies have not been systematically reviewed. The objective of this study is to systematically identify and describe socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions amongst adult populations in economically developed countries reported in high-quality observational studies published in the peer-reviewed literature.

METHODS

Peer-reviewed literature was searched in six health and social science databases: MEDLINE, EMBASE, PsycInfo, CINAHL, ASSIA, and IBSS using search terms for hospitalization, socioeconomic status, and chronic ambulatory care sensitive conditions. Study titles and abstracts were first screened followed by full-text review according to the following eligibility criteria: 1) Study outcome is hospitalization for selected chronic ambulatory care sensitive conditions; 2) Primary exposure is individual- or area-level socioeconomic status; 3) Study population has a mean age ± 1 SD < 75 years of age; 4) Study setting is economically developed countries; and 5) Study type is observational. Relevant data was then extracted, and studies were critically appraised using appropriate tools from The Joanna Briggs Institute. Results were narratively synthesized according to socioeconomic constructs and type of adjustment (minimally versus fully adjusted).

RESULTS

Of the 15,857 unique peer-reviewed studies identified, 31 studies met the eligibility criteria and were of sufficient quality for inclusion. Socioeconomic constructs and hospitalization outcomes varied across studies. However, despite this heterogeneity, a robust and consistent association between lower levels of socioeconomic status and higher risk of hospitalizations for chronic ambulatory care sensitive conditions was observed.

CONCLUSIONS

This systematic review is the first to comprehensively identify and analyze literature on the relationship between SES and hospitalizations for chronic ambulatory care sensitive conditions, considering both aggregate and condition-specific outcomes that are common to several international health systems. The evidence consistently demonstrates that lower socioeconomic status is a risk factor for hospitalization across global settings. Effective health and social interventions are needed to reduce these inequities and ensure fair and adequate care across socioeconomic groups.

TRIAL REGISTRATION

PROSPERO CRD42018088727.

A meta-epidemiological study of subgroup analyses in cochrane systematic reviews of atrial fibrillation

BACKGROUND

Information on subgroup assessments in systematic reviews (SR) of atrial fibrillation (AF) is limited. This review aims to describe subgroup analyses in AF SRs to inform the design of SRs and randomized trials as well as clinical practice.

METHODS

We conducted a cross sectional meta-epidemiological study of Cochrane AF reviews by searching AF (including variants) in the title, abstract, or keyword field without date or language restrictions (Issue 9; September 2018). Two reviewers independently extracted study characteristics to summarize frequency of subgroups pre-specified and conducted and report credibility of subgroup effects claimed.

RESULTS

Of 39 Cochrane reviews identified, 17 met inclusion criteria (including 168 reports of 127 randomized trials) and the majority (16; 94.1%) conducted meta-analysis of outcomes. Most (13; 76.5%) planned pre-specified subgroup analyses; 7 of which (41.2%) conducted subgroups. In these 7 reviews, 56 subgroups were planned, 17 (30.4%) conducted and 6 (10.7%) yielded subgroup effects. Variables such as co-morbid disease, stroke risk factors, prior stroke/transient ischemic attack, age, race, and sex represented 44% (24 subgroups) of all planned subgroups (8 conducted; 14.3%); however, information on covariate selection was lacking. Overall, more subgroups were planned than conducted (mean difference (95% CI) 2.3 (1.2-3.5, p < 0.001)). Of all subgroups conducted, anticoagulant characteristics comprised a third of all subgroup effects (n = 5, 35.7%). The credibility of subgroups identified (n = 14) was assessed and less than half (43%) represented one of a small number of pre-specified hypothesis and rarely were effects seen within studies (7%). Of 5 reviews that reported subgroup effects, only 3 discussed subgroup effects as part of the overall conclusions; none discussed credibility of subgroup effects.

CONCLUSIONS

This meta-epidemiological review of a subset of Cochrane AF reviews suggests that planning and reporting of subgroup analyses in AF reviews can be improved to better inform clinical management. Most pre-specified subgroup analyses were not performed, important variables (such as stroke, bleeding risk, and other comorbidities) were rarely examined and credibility of subgroup effects claimed was low. Future reviews should aim to identify important subgroups in their protocols and use recommended approaches to test subgroup effects in order to better support clinical decision-making.

Amaze: a double-blind, multicentre randomised controlled trial to investigate the clinical effectiveness and cost-effectiveness of adding an ablation device-based maze procedure as an adjunct to routine cardiac surgery for patients with pre-existing atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) can be treated using a maze procedure during planned cardiac surgery, but the effect on clinical patient outcomes, and the cost-effectiveness compared with surgery alone, are uncertain.

OBJECTIVES

To determine whether or not the maze procedure is safe, improves clinical and patient outcomes and is cost-effective for the NHS in patients with AF.

DESIGN

Multicentre, Phase III, pragmatic, double-blind, parallel-arm randomised controlled trial. Patients were randomised on a 1 : 1 basis using random permuted blocks, stratified for surgeon and planned procedure.

SETTING

Eleven acute NHS specialist cardiac surgical centres.

PARTICIPANTS

Patients aged ≥ 18 years, scheduled for elective or in-house urgent cardiac surgery, with a documented history (> 3 months) of AF.

INTERVENTIONS

Routine cardiac surgery with or without an adjunct maze procedure administered by an AF ablation device.

MAIN OUTCOME MEASURES

The primary outcomes were return to sinus rhythm (SR) at 12 months and quality-adjusted life-years (QALYs) over 2 years after randomisation. Secondary outcomes included return to SR at 2 years, overall and stroke-free survival, drug use, quality of life (QoL), cost-effectiveness and safety.

RESULTS

Between 25 February 2009 and 6 March 2014, 352 patients were randomised to the control (n = 176) or experimental (n = 176) arms. The odds ratio (OR) for return to SR at 12 months was 2.06 [95% confidence interval (CI) 1.20 to 3.54; p = 0.0091]. The mean difference (95% CI) in QALYs at 2 years between the two trial arms (maze/control) was -0.025 (95% CI 0.129 to 0.078; p = 0.6319). The OR for SR at 2 years was 3.24 (95% CI 1.76 to 5.96). The number of patients requiring anticoagulant drug use was significantly lower in the maze arm from 6 months after the procedure. There were no significant differences between the two arms in operative or overall survival, stroke-free survival, need for cardioversion or permanent pacemaker implants, New York Heart Association Functional Classification (for heart failure), EuroQol-5 Dimensions, three-level version score and Short Form questionnaire-36 items score at any time point. Sixty per cent of patients in each trial arm had a serious adverse event (p = 1.000); most events were mild, but 71 patients (42.5%) in the maze arm and 84 patients (45.5%) in the control arm had moderately severe events; 31 patients (18.6%) in the maze arm and 38 patients (20.5%) in the control arm had severe events. The mean additional cost of the maze procedure was £3533 (95% CI £1321 to £5746); the mean difference in QALYs was -0.022 (95% CI -0.1231 to 0.0791). The maze procedure was not cost-effective at £30,000 per QALY over 2 years in any analysis. In a small substudy, the active left atrial ejection fraction was smaller than that of the control patients (mean difference of -8.03, 95% CI -12.43 to -3.62), but within the predefined clinically equivalent range.

LIMITATIONS

Low recruitment, early release of trial summaries and intermittent resource-use collection may have introduced bias and imprecise estimates.

CONCLUSIONS

Ablation can be practised safely in routine NHS cardiac surgical settings and increases return to SR rates, but not survival or QoL up to 2 years after surgery. Lower anticoagulant drug use and recovery of left atrial function support anticoagulant drug withdrawal provided that good atrial function is confirmed.

FURTHER WORK

Continued follow-up and long-term clinical effectiveness and cost-effectiveness analysis. Comparison of ablation methods.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN82731440.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 19. See the NIHR Journals Library website for further project information.

Amaze: a randomized controlled trial of adjunct surgery for atrial fibrillation

OBJECTIVES

Atrial fibrillation (AF) reduces survival and quality of life (QoL). It can be treated at the time of major cardiac surgery using ablation procedures ranging from simple pulmonary vein isolation to a full maze procedure. The aim of this study is to evaluate the impact of adjunct AF surgery as currently performed on sinus rhythm (SR) restoration, survival, QoL and cost-effectiveness.

METHODS

In a multicentre, Phase III, pragmatic, double-blinded, parallel-armed randomized controlled trial, 352 cardiac surgery patients with >3 months of documented AF were randomized to surgery with or without adjunct maze or similar AF ablation between 2009 and 2014. Primary outcomes were SR restoration at 1 year and quality-adjusted life years at 2 years. Secondary outcomes included SR at 2 years, overall and stroke-free survival, medication, QoL, cost-effectiveness and safety.

RESULTS

More ablation patients were in SR at 1 year [odds ratio (OR) 2.06, 95% confidence interval (CI) 1.20-3.54; P = 0.009]. At 2 years, the OR increased to 3.24 (95% CI 1.76-5.96). Quality-adjusted life years were similar at 2 years (ablation - control -0.025, P = 0.6319). Significantly fewer ablation patients were anticoagulated from 6 months postoperatively. Stroke rates were 5.7% (ablation) and 9.1% (control) (P = 0.3083). There was no significant difference in stroke-free survival [hazard ratio (HR) = 0.99, 95% CI 0.64-1.53; P = 0.949] nor in serious adverse events, operative or overall survival, cardioversion, pacemaker implantation, New York Heart Association, EQ-5D-3L and SF-36. The mean additional ablation cost per patient was £3533 (95% CI £1321-£5746). Cost-effectiveness was not demonstrated at 2 years.

CONCLUSIONS

Adjunct AF surgery is safe and increases SR restoration and costs but not survival or QoL up to 2 years. A continued follow-up will provide information on these outcomes in the longer term.

Study registration

ISRCTN82731440 (project number 07/01/34).

The long-term efficacy of concomitant maze IV surgery in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and associated with increased risk of morbidity and mortality. AF surgery is widely used for rhythm control of AF, but previous studies have shown varying results. This study sought to investigate the long-term efficacy of concomitant maze IV (CMIV) surgery in an unselected AF population and identify predictors of late AF recurrence.

Methods

In total 144 consecutive patients, who underwent CMIV between January 2006 and December 2010 were enrolled. By data from electronic medical records, registers, and rhythm prints, late AF recurrences and heart rhythm at latest follow-up were retrospectively registered. All patients still alive were invited to an ambulant follow-up to update rhythm status.

Results

During a median (IQR) follow-up of 7.39 (2.67) years, 114 (79.2%) patients had recurrence. The cumulative incidence of sinus rhythm (SR) without antiarrhythmic drugs (AADs) was 52.3% after 1 year. Long-term results after 2, 5 and 7 years were 47.9%, 32.6% and 25.1%, respectively. At latest follow-up 34.7% were in SR off AADs. No difference in 10-year event-free survival stratified by recurrence were found (p = 0.678). Contrary, time to death (5.40 vs. 3.43 years, p = 0.004) revealed death as competing risk event. The Fine-Gray model identified preoperative sustained AF (SAF) (SHR 3.54, 95%CI [2.35;5.32], p < 0.001), AF duration (1.08, [1.05;1.11], p < 0.001), and postoperative atrial tachyarrhythmia (ATA) (2.29, [1.21;4.35], p = 0.011) as predictors.

Conclusion

CMIV in the present cohort provided limited long-term success in obtaining SR. SAF, longer AF duration, and postoperative ATA were associated with late AF recurrence.

The future of atrial fibrillation management: integrated care and stratified therapy

Atrial fibrillation is one of the major cardiovascular health problems: it is a common, chronic condition, affecting 2-3% of the population in Europe and the USA and requiring 1-3% of health-care expenditure as a result of stroke, sudden death, heart failure, unplanned hospital admissions, and other complications. Early diagnosis of atrial fibrillation, ideally before the first complication occurs, remains a challenge, as shown by patients who are only diagnosed with the condition when admitted to hospital for acute cardiac decompensation or stroke. Once diagnosed, atrial fibrillation requires chronic, multidimensional management in five domains (acute management, treatment of underlying and concomitant cardiovascular conditions, stroke prevention therapy, rate control, and rhythm control). The consistent provision of these treatment options to all patients with atrial fibrillation is difficult, despite recent improvements in organisation of care, knowledge about atrial fibrillation, and treatment options. Integrated care models that provide patient-centred care in, or close to, the patient's community while maintaining access to all specialist treatment options, emerge as the best approach to achieve consistent delivery of these chronic treatments to all patients with atrial fibrillation. Ongoing research efforts will establish when to initiate oral anticoagulation in patients with device-detected atrial high-rate episodes, quantify the prognostic effect of early and comprehensive rhythm control therapy, including atrial fibrillation ablation, and delineate optimum methods to reduce bleeding complications in patients treated with anticoagulation. Additionally, research efforts are needed to define different types of atrial fibrillation on the basis of the main causes of atrial fibrillation to pave the way for the clinical development of stratified atrial fibrillation therapy.

Persistent atrial fibrillation vs paroxysmal atrial fibrillation: differences in management

INTRODUCTION

Atrial fibrillation (AF) is the most common human arrhythmia. AF is a progressive disease, initially being nonsustained and induced by trigger activity, and progressing towards persistent AF through alteration of the atrial myocardial substrate. Treatment of AF aims to decrease the risk of stroke and improve the quality of life, by preventing recurrences (rhythm control) or controlling the heart rate during AF (rate control). In the last 20 years, catheter-based and, less frequently, surgical and hybrid ablation techniques have proven more successful compared with drug therapy in achieving rhythm control in patients with AF. However, the efficiency of ablation techniques varies greatly, being highest in paroxysmal and lowest in long-term persistent AF. Areas covered: In this review, we discuss the fundamental differences between paroxysmal and persistent AF and the potential impact of those differences on patient management, emphasizing the available therapeutic strategies to achieve rhythm control. Expert commentary: Treatment to prevent AF recurrences is suboptimal, particularly in patients with persistent AF. Emerging technologies, such as documentation of atrial fibrosis using magnetic resonance imaging and documentation of electrical substrate using advanced electrocardiographic imaging techniques are likely to provide valuable insights about patient-specific tailoring of treatments.