Beyond Pulmonary Vein Isolation

Catheter ablation has become an integral part of the management of atrial fibrillation (AF). Based on the phenomenological observation of ectopic beats arising from the pulmonary veins (PV) as the initiation mechanism of AF and subsequent evidence of efficacy from randomized clinical trials, PV isolation (PVI) has been the undisputed procedural technique for more than 2 decades for paroxysmal AF ablation. Although not uniformly effective, its shortcomings have been attributed to the technical limitations of catheter techniques and technologies in achieving complete and durable PVI-technical failures, rather than mechanistic paradigm failures.