Left atrial ablation pendulum swinging back towards the pulmonary veinsThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

Abstract

This editorial refers to ‘Non-inducibility post-pulmonary vein isolation achieving exit block predicts freedom from atrial fibrillation’† by V. Essebag et al., on page 2550 No cardiologist today is ignorant anymore of the fact that the pulmonary vein (PV) ostia and the surrounding left atrial (LA) tissue lie at the heart of atrial fibrillation (AF). The PVs may harbor rapidly firing foci that act as triggers for the initiation of paroxysms of AF. Moreover, the region certainly also plays a key role in its perpetuation towards persistent or even permanent forms by harboring fast re-entrant wavelets that maintain the arrhythmia. Since the original reports, describing selective ablation of foci within the PV, ablative strategies have moved towards the ostia and further away from the veins into the left atrium. However, despite intense research, it remains unclear what is the best ablation strategy for AF. Over the last decade, two main ‘schools’ have developed. The first is directed at the electrical isolation of the PV from the left atrium, a goal which is generally achieved by directing RF applications to the ostium of the veins.1 Therefore, it is referred to as pulmonary vein isolation (PVI). Others have taken a more anatomical approach, encircling the PV with RF lesions.2 The endpoint of these ablations is less uniform, although attenuation of electrogram amplitude within the ablated region might be used as an endpoint. The latter approach is more diverse among different centres, but as a group, these procedures are referred to as circumferential pulmonary vein ablation (CPVA). A clear superiority for either technique has not emerged from the limited data available comparing the two approaches.3 Both have in common, however, that 20–58% of the patients have recurrent AF after 6 months to 1 year, despite attaining the procedural endpoint. It is … *Corresponding author. Tel: +32 16 34 42 48; fax: +32 16 34 42 40. E-mail address : hein.heidbuchel{at}uz.kuleuven.ac.be