Three new studies presented during ESC Congress 2026 are shedding light on how best to treat and manage atrial fibrillation (AFib). From catheter ablation strategies to rhythm-control procedures and tailored exercise programs, the IDEAL-AF, NEXAF and PVI-SHAM-AF trials provide fresh evidence on interventions that could improve outcomes and quality of life.

IDEAL-AF Trial
In IDEAL-AF, simultaneously published in JAMA, adjunctive low-voltage zone ablation following pulmonary vein isolation improved rhythm outcomes and health-related quality of life without increasing serious adverse events in patients with persistent AFib and significant low-voltage zones.

The results found that patients who were randomized to individualized adjunctive low-voltage zone ablation after pulmonary vein isolation more frequently achieved the primary outcome of arrhythmia-free survival. Time to first recurrence after a single ablation procedure without antiarrhythmic drugs also favored low-voltage zone ablation, according to researchers. Additionally, improvements in health-related quality of life were greater in the low-voltage zone ablation group, while rates of serious adverse events were similar in groups.

These findings support a low-voltage zone–guided ablation strategy in this population, said Astrid Paul Nordin, MD, PhD, et al.

In a related editorial comment, Peter M. Kistler, MBBS, PhD, and David Chieng, MBBS, PhD, note that “IDEAL-AF, with its stricter trial design, shifts support toward atrial mapping and individualized adjunctive low-voltage zone ablation, present in a minority of patients.” Ultimately, however, they write that “the jury remains out on whether a tailored or empirical ablation strategy will improve outcomes in patients with persistent AFib, but with better, more detailed mapping and large-footprint dual-energy technology, the future is bright.”

NEXAF Trial
In NEXAF, a one-year tailored exercise program combining short-term supervision with long-term home-based exercise, significantly reduced AFib burden, improved cardiorespiratory fitness and reduced hospitalizations compared with usual care. However, major improvements in quality of life were not observed.

The trial included 295 patients from Norway (mean age of 64 years; 30% women) who were randomized to usual care with no structured or supervised exercise programs or an exercise intervention consisting of eight supervised high-intensity sessions during the first four to six weeks, followed primarily by remote exercise monitoring and guidance using a smartwatch, app and a web-based platform. All participants were implanted with an insertable cardiac monitor.

According to Bjarne Nes, PhD, who presented the study, the program proved feasible in routine clinical practice and could facilitate broader adoption of guideline-recommended exercise-based rehabilitation, a therapy that remains underused despite its proven benefits.

PVI-SHAM-AF
In the PVI-SHAM-AF trial, simultaneously published in The Lancet, catheter ablation for AFib did not significantly improve AFib-related quality of life compared with a sham procedure, despite reducing the recurrence of AFib.

The trial, conducted at nine sites in Germany and Poland, randomized 262 patients (2:1) with symptomatic paroxysmal or persistent AFib undergo catheter ablation or a sham procedure. All completed an AFib Effect on the Quality of Life Questionnaire at baseline and at six months.

Researchers highlighted that while quality of life summary scores improved in both groups, there was no significant difference (61.3 to 81.1/Ablation Group; 59.2 to 74.9/Sham Group). Freedom from AFib after six months was substantially higher in the catheter ablation group (73%) compared with the sham group (52%), however.

“While patients often say that their quality of life has improved after a procedure, it appears from our trial findings that most of this improvement is not attributable to the catheter ablation, but to other factors. These could include a placebo effect, optimization of therapies or other factors,” said Rolf Wachter, MD, from the University of Leipzig Medical Centre in Germany. He added that selection bias may have played a role in the study results.

Visit ACC’s ESC Congress 2026 coverage page to explore the latest science and key takeaways shaping cardiovascular care.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Geriatric Cardiology, Prevention, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Exercise

Keywords: ESC Congress, ESC26, Atrial Fibrillation, Frailty, Multimorbidity, Polypharmacy, Aged, Catheter Ablation, Pulmonary Veins, Exercise Therapy, Cardiac Rehabilitation, Electrophysiologic Techniques, Cardiac