Pulmonary Vein Isolation: Cornerstone of Atrial Fibrillation Ablation and Its Evolving Challenges. A Critical Review

AF is the most common cardiac arrhythmia, affecting millions worldwide. Catheter ablation has evolved into a cornerstone treatment for AF, offering better rhythm control and symptom relief than antiarrhythmic medications in selected patients. Over the past few decades, AF ablation has evolved significantly. Initially, right atrial approaches were explored before shifting to the left atrium, with pulmonary vein isolation emerging as the principal strategy. Attempts at substrate modification, including complex fractionated atrial electrograms ablation, linear lesions and rotor-based approaches, have been explored, but yielded inconsistent results. Recent studies reaffirm pulmonary vein isolation as the cornerstone of AF ablation. This review critically evaluates the evolution of AF ablation, the scientific rationale behind different strategies, technological advancements and future directions in the field.