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Address reprint requests and correspondence: Dr. Andrea Natale, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Desk F15, 9500 Euclid Avenue, Cleveland, Ohio 44195.
Atrial fibrillation (AF) is one of the 20th-century epidemics. Over the past 2 decades,
significant advances have been made in the treatment of AF, the last being percutaneous
ablation. Haissaguerre et al
showed that AF triggers often originate from the thoracic veins. The goal of present-day
AF ablation is to electrically “disconnect” the pulmonary veins (PVs) from the rest
of the left atrium (LA) by ablating around the origin of the veins.
At present, at least two techniques are used for AF ablation. The first is an anatomic
approach guided by nonfluoroscopic navigation systems (e.g., CARTO (Biosense Webster,
Diamond Bar, CA), NavX (St Jude Medical, St Paul, MN), LocaLisa (Medtronic, Minneapolis,
MN)), in which radiofrequency (RF) ablations are delivered circumferentially outside
the PV ostia with a variety of additional ablation lesions without necessarily demonstrating
complete electrical isolation.
The second approach, which is performed at the Cleveland Clinic, requires electrical
isolation of the entire PV antra as the endpoint. This is achieved by a circular mapping
technique with the use of intracardiac echocardiography for guidance (Figure 1).
Figure 1Anatomic definition of pulmonary vein ostium and antrum using three-dimensional computed
tomographic imaging (A) and intracardiac echocardiography (B). Note that the right and left pulmonary vein antra include the posterior wall of
the left atrium. LSPV = left superior pulmonary vein; RSPV = right superior pulmonary
vein.
