Circles and lines: are we opening the Pandora's box of non-paroxysmal atrial fibrillation ablation?

This editorial refers to ‘Prospective randomized comparison between a fixed ‘2C3L’ approach vs. stepwise approach for catheter ablation of persistent atrial fibrillation’ by J.-Z. Dong et al ., on page 1798–1806. Catheter ablation for rhythm control in patients with non-paroxysmal atrial fibrillation (AF) is challenging. The latest guidelines for AF management give a class IIa (Level of Evidence A) and class IIb (Level of Evidence B) recommendation for catheter ablation of persistent and long-standing persistent (LSP) AF, respectively.1 This arises from the poor success rates reported in several studies (45–60% after a single procedure) and an increased risk of complications when extensive radiofrequency ablation is attempted.2 Moreover, many studies in non-paroxysmal AF are observational, using different strategies with different procedural endpoints that are often subjective and reproducible only by expert operators. As a result, an important variation in success rates is observed and no consensus exists as to the optimal ablation strategy. Isolation of the pulmonary veins (PVs) and their embryological sibling, the posterior wall (the so-called pulmonary vein antral isolation, PVAI) is an essential step, but to achieve long-term success it is important to take it further.2,3 The importance of extending the ablation to non-PV sites is related to the significant structural and electrophysiological changes that take place …