Catheter ablation for atrial fibrillation (AF) is a procedural treatment option that has yet to find its final place in AF rhythm management. So far, other than pulmonary vein isolation, it does not have an indisputable mechanistic basis. It is empirical, not truly individualized on the basis of a diagnostic procedure. Success for the procedure is usually couched in terms of a measure of recurrence of AF. Existing data concerning recurrence have several confounders. Recurrence data are often subjective: They are based on surveys and symptoms rather than objective electrocardiogram (ECG) determination of recurrence, patients are highly selected, concurrent use of antiarrhythmic drugs is included or excluded, redo procedures may or may not be included, and follow-up is frequently a year or less. The nature of the AF (paroxysmal, persistent, long-standing persistent) greatly impacts success rates, which range from 20% to 85%. The procedure is probably infrequently a lifelong "cure" for AF. Best estimate of the risk of a complication from each procedure is about 4.5%, the commonest being tamponade (1.3%), vascular access complications (1.5%), and stroke or transient ischemic attach (1%). Risk of a fatal complication is estimated at 0.15%. There is no convincing evidence that the procedure decreases the risk of death, stroke, or hospitalization for heart failure, but the available randomized trials have enrolled patients inappropriate for assessment of impact on these clinical outcomes. Much remains to be done. Currently the procedure is indicated for relief of symptoms in selected patients, usually who have failed antiarrhythmic drug therapy.
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