How to make sure complications are avoided after an otherwise safe procedure.

Vascular access clearly remains a problem in this report, while a venous femoral puncture, to provide access for a single ablation catheter, should not be a The paper in this issue by Buys et al. is interesting. It was well written and addresses the important clinical issue of the timing and modalities of pacemaker implantation around the procedure of His bundle ablation (HBA). The authors use this clear descriptive term for what is generally called AV junctional ablation. This intervention, which is performed for persistent or paroxysmal atrial fibrillation, should result in complete heart block to make patients less symptomatic, and possibly to improve heart failure, when atrial fibrillation affects cardiac function. A year ago a ‘think-tank’ of cardiologists drew up guidelines on how to perform this procedure, and suggested what precautions needed to be taken to avoid pacemaker-related complications. This group suggested avoiding one particular setting: HBA, followed 24 h later by implantation, as this implied temporary and thus unreliable pacing. The material providing data for this observational study by Buys et al. comes from the era before this publication, and from a centre with an outstanding reputation for cardiac pacing and cardiac electrophysiology in the Netherlands. Therefore, it is possible that real life in the Netherlands and in Europe may be worse than is reported here, even when interventions such as ablation are restricted to a limited number of centres, with the pacing procedure being carried out in the general hospital, as is reflected in the design of this study, and may be common practice in other countries than the Netherlands. The background of this study, as outlined by this group, is that economic restrictions prohibit implantation of pacemakers by the centre performing the HBA, because device therapy is a too costly procedure for the ablating hospital (this is well known by the authors, who nevertheless produced a nice variant of ‘newspeak’ to hide this fact). A general cardiologist, not involved in the daily decision process leading to HBA, may have many questions when reading this article. Indeed, not all logical questions are addressed, and I will try to answer a few, starting from some interesting points raised in this paper and in the related literature on this procedure. What is an acceptable complication rate?