Data comparing the effectiveness of
Data comparing the effectiveness of CFAE ablation and LA linear ablation for eliminating long-standing persistent AF is lacking. However, Estner et al. recently showed that CFAE ablation plus PVI in patients with persistent AF ablation approached the same effectiveness as circumferential PVI plus line within the first year after a single ablation procedure . Prospective, randomized studies comparing the effectiveness of CFAE and line ablation with the baseline PVI protocol are needed to determine the actual effectiveness of each adjunctive ablation method.
Endpoint of catheter ablation for long-standing persistent AF There remains a debate on the endpoint of ablation for long-standing persistent AF cases. O\'Neill et al. reported that procedural AF HMBA Linker during stepwise ablation, involving PVI, CFAE-ablation, and linear atrial ablation, had a better subsequent clinical outcome than cases without procedural AF termination, and suggested AF termination as the desirable endpoint of the procedure . However, this result has not been reproducible in other studies. Recently published data by Lo et al.  and Elayi et al.  showed similar results; cases both with and without procedural AF termination had similar subsequent clinical outcomes and AF termination is a phenomenon that is likely to be achieved only in less advanced cases. When we look back at the paper by O\'Neill et al. , we observed a significant difference in the baseline characteristics of patients with and without procedural AF termination, which suggests that AF termination itself may only be a surrogate for less advanced atrial disease. It is still not clear whether continued RF applications with prolonged procedure time using AF termination as the endpoint will provide a benefit to patients or not.
Indication for catheter ablation for long-standing persistent AF As shown above, the clinical outcome following the ablation procedure has demonstrated that not all patients can benefit from ablation. We now focus on how we can determine who will be a good candidate for operation prior to the procedure. Several clinical variables have been shown to be correlated with ablation procedure outcome in patients with long-standing persistent AF, including the left atrial dimension on echocardiogram and the duration of persistent AF. McCready et al.  demonstrated that LA size (larger than 43mm) was an independent predictor of AF recurrence following ablation of persistent AF. In contrast, Matsuo et al.  showed that both the surface electrocardiographic AF cycle length (≤142ms) and the duration of continuous AF (>21 months) are predictive of AF recurrence after persistent AF ablation. To avoid harmful procedures in highly advanced cases, we need additional criteria to determine the appropriate indications for catheter ablation in patients with long-standing persistent AF.
Conflict of interest
Approach to antiarrhythmic drug therapy
Preventive efficacy of antiarrhythmic drugs
QOL and cardiovascular prognosis in patients with paroxysmal AF Paroxysmal AF is an arrhythmia that should be actively treated and controlled, as it causes deterioration of QOL and cardiovascular complications such as thromboembolism and congestive heart failure (CHF) , and also decreases survival in patients with impaired left ventricular function . Evaluation for QOL can be conducted using a comprehensive tool such as the medical outcomes study short form health survey (SF-36) or, specifically for underlying heart disease, the atrial fibrillation quality of life questionnaire (AFQLQ). According to large Western clinical trials, there are no significant differences in QOL between patients treated with rhythm control therapy and those treated with rate control when analyzed by SF-36 [41–43]. However, a comprehensive tool such as the SF036 is not always suitable for the evaluation of QOL in patients with underlying heart disease. On the other hand, AFQLQ is considered to be a specific tool for the evaluation of limitation of daily life, psychological anxiety, and general discomfort, including medication side-effects, in patients with AF . The J-RHYTHM study has demonstrated that QOL is superior for patients treated with rhythm control therapy compared to those treated with rate control therapy using AFQLQ in Japanese patients with paroxysmal AF . Another Japanese study has revealed that reducing the incidence of AF recurrence is important for improving QOL in patients with paroxysmal AF .