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One Size Doesn't Fit All: AF Ablation, Complications, and Patients with Structural Heart Disease

Catheter ablation for atrial fibrillation (AF) has become a widely accepted therapy for appropriate patients, typically those with AF that is highly symptomatic and refractory to therapy with antiarrhythmic medications.1 And while enthusiasm for ablative AF therapy continues to grow, AF ablation remains a challenging and imperfect procedure.2 Over the last decade there has been a rapid evolution in the strategies used during ablative AF therapy. Focal and segmental ablation has given way, in most centers, to wide-area circumferential pulmonary vein isolation; new targets, including rotors and autonomic ganglia, are under investigation. At the same time, a parallel evolution in ablative technologies has occurred, with the advent of irrigated catheters, cryoablation, and balloon-based therapies. And yet, despite undeniable progress in terms of AF ablation theory and practice, longterm single-procedure success rates remain frustratingly low and complication rates stubbornly high when compared with other catheter-based electrophysiological procedures. Ablation strategies and technological advancements to optimize the benefit-to-risk calculation of AF ablation are critical to delivery of safe and effective therapy, but only insomuch as they serve to inform the central question facing practitioners and patients considering AF ablation: does a particular patient’s constellation of symptoms and substrate (age, gender, comorbidities) justify the risks inherent with catheter ablation? In the current issue of Journal of Cardiovascular Electrophysiology, Hoffmann et al. provide important data on the relationship between patient substrate and observed periprocedural complication rates from PVI for AF, providing useful information to help with that central consideration of substrate and procedural risk.3 The authors provide analysis from the German Ablation Registry (GAR), in which periprocedural complications were catalogued in 6,211 patients undergoing PVI (roughly 90% of patients) or other ablative approaches (linear, segmental, or focal). Ablations were performed at 55 centers from 2007 to 2011. Such large patient volumes allowed the authors to stratify patients by presence and type of structural heart disease (HD), including those free of HD, those with hypertensive HD (HHD), those with coronary artery dis-