Can tailored ablation procedures successfully eliminate recurrent atrial fibrillation?

John M Miller* and Girish V Nair

This article has no abstract so we have provided the first paragraph of the full text.

Oral et al. provide another fine study that presents a practical approach to a difficult clinical problem: achieving optimum results in catheter ablation of AF. Several seemingly divergent techniques for ablation of this common arrhythmia exist that yield very similar—and imperfect—outcomes.^{1, 2, 3} The authors propose using what they call a "tailored approach", in which each patient's ablation procedure is customized to the patient's own pathophysiology according to an orderly progression of techniques. Oral et al. started the procedure by initiating AF, and used a stepwise approach to eliminate the arrhythmia, first looking for drivers in pulmonary veins, which were then isolated using one of several techniques. If a pulmonary vein had potentials but did not appear to be a driver, it was not necessarily isolated. Sites of complex fractionated left atrial electrograms were then systematically sought and targeted for ablation. After ablation in the left atrium, other potential target sites were identified and treated until AF could not be induced or all conceivable targets were ablated (the common endpoint). Posterior left atrial ablation—which can result in esophageal injury—was thus not routinely needed. The authors found that, predictably enough, various approaches were ultimately successful, with no single technique working in even a majority of patients. Follow-up found that 77% of patients had no recurrent AF, though nearly one in five patients required repeat ablation.

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