Brief commentary

Excerpt

We read with interest the study by Worck et al. on “Posterior wall isolation in persistent atrial fibrillation. Long-term outcomes of a repeat procedure strategy” in the current issue of the journal. In this prospective study, durable (“reinforced”) posterior wall isolation (PWI) achieved during a repeat, mandatory ablation procedure following an initial pulmonary vein isolation with concomitant PWI using a “box” approach was associated with reduced long-term freedom from arrhythmia recurrence in patients with persistent atrial fibrillation (AF). These results are consistent with the notion that the technique/methodology by which PWI is performed can influence clinical outcomes. As previously illustrated by the same authors (Worck et al. J Cardiovasc Electrophysiol 2022;33:1667–74), successful/durable PWI is challenging using a “box” strategy, alone. Meanwhile, a large meta-analysis (Jiang et al. JACC Clin Electrophysiol 2022;8:605–18) recently found that PWI using a “box” approach was in fact associated with significantly higher AF recurrences as compared with a “non-box”/direct posterior wall ablation technique, irrespective of energy modality (i.e., cryoenergy or radiofrequency). Another prior study (Saad et al. J Atr Fibrillation 2014;7:1174) has also shown that a “box” PWI strategy validated through detailed and meticulous interrogation of the linear lesions is associated with superior clinical efficacy. These findings strongly and consistently suggest that when examining the outcomes across various clinical studies, one should absolutely differentiate between the PWI techniques that were specifically employed. …