Adjunct ablation strategies for persistent atrial fibrillation—beyond pulmonary vein isolation

Atrial fibrillation (AF) is the most common sustained arrhythmia. Recent guidelines recommend pulmonary vein isolation (PVI) as the main procedural endpoint to control recurrent AF in symptomatic patients resistant to antiarrhythmic drugs. The efficacy of such procedure is higher in paroxysmal AF while is still unsatisfactory in persistent and long-standing persistent AF. This review will summarize the state-of-the-art of AF ablation techniques in patients with persistent AF, discussing the evidence underlying different approaches with a particular focus on adjunctive ablation strategies beyond PVI including linear ablation, ablation of complex fractionated atrial electrograms (CFAE), ablation of ganglionated plexi, dominant frequency, rotors and other anatomical sites frequently involved in AF triggers.