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Pulmonary Vein Isolation Without Reconnection: A Decade of Trying

As the first decade of the 21st century has ended, after reviewing progress in the field of clinical electrophysiology, historians will likely place catheter ablation of atrial fibrillation (AF) as the most important development in this period— ahead of cardiac resynchronization therapy for treatment of congestive heart failure. Interestingly, despite growing acceptance of catheter ablation for supraventricular tachycardia at the beginning of the last decade, physicians had either a lukewarm or even cynical view of AF ablation because this approach was: (1) merely targeting the culprit pulmonary vein (PV) foci triggering AF, (2) quite limited by the long procedure time needed to identify the AF triggers, and (3) associated with a low success rate.1,2 Many investigators also believed that most of the AF triggers came from multiple PV sites, which needed to be ablated to stop AF recurrences. Subsequent research suggested that all PVs were also capable of perpetuating AF. This led to the notion that all 4 PVs needed to be ablated to maximize the efficacy of radiofrequency (RF) ablation. Fortunately, Haissaguerre et al. described mapping of the PV potentials using a specially designed circular catheter that could be positioned at the PV ostia, enabling one to evaluate electrical connection between PV muscle sleeves and the left atrial muscle, making isolation of the electrical impulse between the PV and left atrium easily and reproducibly ascertained.3,4 The PV isolation (PVI) technique gave electrophysiologists a new tool to treat AF with a catheter approach and instantly became almost synonymous with AF ablation. Indeed, it became so popular that PVI is now the most commonly performed electrophysiology procedure in many leading electrophysiology laboratories. Thus, in the same way as other disciplines such as news or sports media select the most important event of the decade, PVI for AF ablation will likely be voted the electrophysiology procedure of this past decade. There are many reasons why PVI became so popular: first, PVs are anatomically fixed targets, despite variability