Pulmonary vein isolation with the pulmonary vein ablation catheter (PVAC): is there a price to pay for a 'simpler', shorter procedure?

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This editorial refers to ‘Efficacy of multi-electrode duty-cycled radiofrequency ablation for pulmonary vein disconnection in patients with paroxysmal and persistent atrial fibrillation’ by R.P. Beukema et al ., on page 502. Pulmonary vein (PV) isolation (PVI) is currently the most well-accepted ablation strategy for the treatment of atrial fibrillation (AF) because of the demonstration of a pathophysiological role of PV myocardium and a simple and unambiguous endpoint. The technique as originally described utilizes one circumferential mapping catheter placed within the PVs and another ablation catheter in the left atrium (LA) sequentially targeting earliest activation from the LA into the PVs.1 A third catheter placed in the distal coronary sinus is mainly useful to distinguish far-field LA activation from local PV myocardial activation in the left PVs. Appropriate ablation progressively isolates the PV by disconnecting each LA input one by one. Two variants of PVI are practised: circumferential PV ablation (CPVA) which relies on the anatomical creation of a complete isolation barrier and the segmental technique or its variants which depend upon electrical activation to pinpoint the precise input(s) and perform targeted ablation. Although the CPVA technique started life as a single (ablation) catheter-based technique, both techniques as currently practiced require appropriate and stable positioning of two catheters, one to ablate and the other to map and verify isolation. The circular mapping catheter once introduced within a PV of choice should be stable enough to allow the operator to use both hands to manipulate the ablation catheter tip to desired locations around the PV ostial circumference. For anatomical reasons however, this is frequently difficult with the right inferior PV (RIPV) and successful isolation often seems to require more than two hands (or an obedient and stoic assistant!). Both PVI procedures are time consuming including the time taken for each individual ablation, … *Corresponding author. Tel: +41 22 3727202; fax: +41 22 3727229, Email: dipen.shah{at}hcuge.ch