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Catheter ablation of atrial fibrillation (AF) has evolved from a procedure that targeted only the culprit ectopic foci that initiated AF from inside the pulmonary veins of patients with paroxysmal AF to procedures that electrically isolate all pulmonary veins from the left atrium (LA). AF ablation procedures currently often incorporate extensive atrial ablation targeting incompletely understood phenomena such as complex fractionated atrial electrograms (CFAE), involve the creation of a simplified ‘maze’ procedure or combinations of these thereby extending AF ablation to treat patients whose AF has become persistent or ‘permanent’. This editorial reviews the evolution of AF ablation to its current practice and explores future possibilities.
The seminal paper for AF ablation was published in 1998 by Haissaguerre et al.1 The authors described the role of pulmonary vein triggers in initiating AF and how ablation of these rapidly firing foci could prevent the recurrence of paroxysmal AF in patients who had not been controlled by several antiarrhythmic drugs. In the early years of AF ablation, only culprit or spontaneously firing veins were treated by ostial or intrapulmonary vein ablation. However, the high arrhythmia recurrence rates, the increasing recognition that all pulmonary veins have the potential to initiate AF, improved mapping tools and familiarity with catheter manipulation in the posterior LA have all led to it being routine practice to isolate all four pulmonary veins electrically from the LA. This is now the first aim of all AF ablation procedures, irrespective of the presenting pattern of AF.
There has been much ‘learning while burning’, during the growth of AF ablation. It quickly became apparent that radiofrequency ablation within the pulmonary veins can result in pulmonary venous stenosis. When severe, this complication can be extremely symptomatic for the patient and problematical to treat, with a high recurrence rate even after …