Catheter ablation for the treatment of persistent atrial fibrillation: Maintenance of sinus rhythm with left atrial appendage and coronary sinus isolation after multiple ablation procedures

Introduction After seminal research demonstrated the pulmonary veins (PVs) and PV antrum contained substrates that can initiate and perpetuate paroxysmal atrial fibrillation (AF) in the majority of patients, catheter ablation with circumferential pulmonary vein isolation (PVI) has become the cornerstone treatment for the management of paroxysmal AF. However, in patients with persistent and long-standing persistent AF, singleand multiple-procedure recurrence rates remain high. Therefore, further ablation of left atrial and right atrial lines, ablation of complex fractionated atrial electrograms (CFAE), and, recently, the targeting of focal sources have been performed, with mixed results. We report on the results of multiple catheter ablation procedures in a patient with persistent AF, eventually targeting 2 specific AF substrates within the left atrial appendage (LAA) and coronary sinus (CS) after extensive ablation, including circumferential isolation of the ipsilateral PVs and superior vena cava (SVC), extensive CFAE ablation within the left atrium (LA) and right atrium (RA), and multiple linear lesions in both atria.