BEAT-PERS AF: Rethinking Ablation Strategies in Persistent Atrial Fibrillation

How does the BEAT PERS AF results presented at EHRA 2026 refine our understanding of the optimal ablation strategy for patients with persistent atrial fibrillation?

Thank you for that question, because I think it’s really important. What I delivered during the late breaking presentation is that in BEAT-AF, we randomized pulse field ablation (PFA) versus radiofrequency (RFA) in a small number of patients when it comes to persistent AF because we had no budget to do more. And it’s a 2:1 randomization in favor of PFA, so in total, 52 patients PFA and 31 received RFA was the closed protocol. In both groups, it is pulmonary vein isolation (PVI) plus a posterior line in the left atrium.

In terms of efficacy, we observed that after 1 year follow-up, we had 65% success rate with PFA compared to 55% with RFA. It is not significant in any way; this trial wasn’t designed to demonstrate a superiority. But the null hypothesis was rejected; it was 40%, and in fact, we even reached the superior bar that was set at 60%.

So it’s pretty encouraging, and it makes me think two things: one is that it is possible that with more patients enrolled, we would have had a superiority demonstrated; two, I think that we are not taking care enough of patients with persistent AF. The field for historical reasons has been focusing mostly on paroxysmal AF, and if you look at the guidelines, they are oriented towards paroxysmal AF. But the patients exposed to worse complications and poorer outcome are those with persistent AF, and we now know that the AF burden is really linked and predictive of those complications. So those patients should be our priority. And if I was to redo this trial, I would focus only on persistent AF, I think.

How do the clinical outcomes, particularly in terms of freedom for those with atrial fibrillation and need for repeat procedures, compare with existing standard of care approaches?

This is a very important question and this is why we have to consider randomized control trials, particularly when it comes to persistent AF, because this is not a homogeneous group of patients. So you have a success rate with PVI only, which is not our design here, but with PVI only, to give you an idea of how variable it is, you can get a 1-year success r ate of 20% or up to 65% – so this is highly heterogeneous. And this is why, I can’t really tell how it compares because it is just too heterogeneous. What I can say is that, in this study, we had slightly superior results with pulsed field ablation, with no knowledge whether it is significant or not, because the trial was not powered for that.

Were there any notable safety signals or procedural trade-offs identified, especially in relation to more extensive sub-trait modification strategies?

Yes, absolutely, and my motto here is that in persistent AF, the best ablation strategy is the one that restores sinus rhythm at the least tissue cost. I think this is very important. We’re not here to kill everything. Yes, you can be successful wiping out the left atrium, but then there is no function left. And those cells are here for something – they are contributing to the heart function, they have endocrine functions as well. It is really important to respect, as much as possible, the heart and the cardiac function. So we had no signal that this PVI plus, because we had this posterior lesion, was providing complications in excess, as compared to what was expected.

Now, if I get a little bit into more detail: we only had one complication in the 52 patients with PFA, and this complication is from a protocol violation. In one center, a cavo-trachespid isthmus ablation for typical flutter was performed with the pulse field ablation, which was against the protocol, and without protection from nitrates. The patient had a coronary spasm, and then they infused nitrates, and it resolved with no consequences for the patient. But again, this is the only complication and it’s a protocol violation.

In the RF group, we had more complications. We had 4 patients with pulmonary vein stenosis in excess of 50%, and we had 2 vascular access complications, which is surprising to me because we had the same signal in paroxysmal AF. You would expect vascular complications at the puncture site to be superior with PFA because it’s a bigger shift, and yet it’s the opposite. We also had, and this is more interesting, one esophageal ulcer in the RF group, which is expected. This is the minor version of fistulas. This patient had no fistula, but he had to be hospitalized for 3 days, with some intravenous (IV) proton pump inhibitors and IV food as well, so it’s not benign, and it’s one of the reasons why I feel so much better now that I have pulsed field ablation for my patients, because the risk for the esophagus is gone, and the risk for pulmonary vein stenosis is gone as well, which is pretty remarkable with pulse field ablation as compared to RF.

Based on these findings, how do you envision integrating BEAT-PERS-AF into current guidelines and decision-making pathways for managing persistent AF?

That’s another contribution to the fact that pulse field ablation, in fact, should be used to revisit everything we did in the past. I mean that there is still no consensus beyond pulmonary vein isolation to treat persistent AF patients. Pretty much everything we did was not consistent enough to be consensual and adopted in the guidelines. I’m pretty sure that with pulse field ablation and appropriate catheters, we can demonstrate that PVI plus linear lesions is superior to PVI only, and my highest desire now is to have this kind of study performed.

The good thing with persistent atrial fibrillation is that it’s there at the time of the enrollment, and it is pretty easy to demonstrate that there is a huge benefit in terms of AF burden, which, in my opinion, should become the new endpoint for future trials; the 30 seconds rule is not a good thing. I’ll give you a comparison, which I think is very relevant: when you have a patient with blood hypertension and treated by a drug X, if you have 95% or 99% of the time a perfect control of the blood pressure, and if from time to time you get 150 systolic blood pressure, you are not considering this as a failure – it’s a success. It’s the same with atrial fibrillation. Now that we know that there is a direct relationship between AF burden and the consequences on health, that should be our end point for the future.