Large Circular Ring Catheter Ablation Versus Anatomically Guided Ablation of Atrial Fibrillation: Back to the Future for Successful Catheter Ablation of Atrial Fibrillation?

Radiofrequency catheter ablation of atrial fibrillation (AF) is an effective rhythm control strategy, and its efficacy has been proved to be superior to anti-arrhythmic drugs.1-3) Recently, the European Society of Cardiology’s 2010 revised guidelines for AF management suggested catheter ablation as the firstline treatment in patients with paroxysmal lone AF.4) When Haissaguerre et al.5) initially reported catheter ablation of AF, it was focal ablation of the pulmonary vein (PV) origin of AF. The rationale for PV ablation was the existence of arrhythmogenic Purkinje fibre-like cells inside the PV,6) and reproducible PV triggers initiating AF.7) In 2002, multipolar circular ring catheter for mapping of the PV was introduced in performing catheter ablation of AF. Multipolar ring catheter is useful for the detection of arrhythmogenic PV and specific localization of foci triggering AF.8) Therefore, multipolar circular ring catheter guided segmental ostial ablation of arrhythmogenic PV was the standard therapy for AF ablation in the early and mid 2000s. However, there is a substantial risk of PV stenosis associated with ostial ablation after RF energy delivery. Therefore to reduce the risk of PV stenosis, the ablation strategy has changed to circumferential PV isolation at the level of PV antrum, which is 10-15 mm outside the PV ostium.9) Although reproducibly defined arrhythmogenic PV isolation demonstrates a clinical outcome comparable with empirical 4-PV isolation,10) most of the patients with AF who underwent catheter ablation have multiple PV foci in multiple veins and hence circumferential bi-antral ablation with electrical isolation of 4 PVs became the cornerstone of catheter ablation of AF.