Mental Exit Block
Escaping the Pulmonary Veins in Search of New Approaches to Atrial Fibrillation Management
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Article, see p 1068
“The significant problems we face cannot be solved at the same level of thinking we were at when we created them.”
— Albert Einstein
The pulmonary vein (PV) has been a source of fascination for electrophysiologists ever since the landmark work of Haissaguerre et al first showed that the PVs were a common source of atrial fibrillation (AF) triggers.1 The distinct embryological origins of PV tissue were thought to predispose these sites to be repositories of ectopy and thereby AF. Initial therapeutic approaches reliant on targeting individual pulmonary vein triggers evolved to segmental pulmonary vein isolation and, at present, wide area antral isolation.2–4
Unfortunately, improvements in ablation efficacy have been only incremental. The first descriptions of PV isolation as ablative therapy for atrial fibrillation (AF) described success rates of 63%.5 This large failure rate was initially due to technical limitations, as acute successes in the laboratory often gave way to chronic reconnection at repeat procedures. In the current era, technology has begun to catch up with our intellectual understanding of AF. Tools like JET ventilation, force-sensing catheters, and newer electro-anatomic mapping systems have improved the ability to create durable isolation of the PVs. Yet even in the best of circumstances, in patients with paraxoysmal AF and minimal comorbidities, the long-term freedom from reoccurrence after AF ablation approaches only about 80%.6 By comparison, other ablative procedures, such as typical isthmus dependent right atrial flutter or atrioventricular nodal reentrant tachycardias, have durable therapeutic success rates in excess of 95%.
This raises the …