1 , INTRODUCTION: One of the great conundrums in catheter ablation for atrial fibrillation (AF) is how to balance safety and efficacy. Truly transmural lesions are required to cause permanent electrical conduction block; however, nearby extracardiac structures pose risks with excessive ablation. This is particularly relevant when ablating on the left atrial posterior wall (LAPW), which lies in close proximity to the esophagus. Indeed, atrioesophageal fistula, whilst extremely rare, remains the most feared complication of AF ablation. The LAPW shares embryological connections with the pulmonary veins, making it a natural target for AF ablation. Trials and meta-analyses have, however, found conflicting evidence for posterior wall isolation (PWI), with some in favor and others against. There is, therefore, a need to conclusively answer the question—Does PWI improve outcomes for patients with persistent AF, beyond pulmonary vein isolation (PVI) alone? And can it be achieved safely?
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