Catheter ablation has become an established treatment for atrial fibrillation (AF). The number of AF ablations in the US has increased exponentially over the past decade from an estimate of 75 000 procedures yearly in 2013, to an estimate of 240 000 procedures in 2020. Factors that have contributed to this increase include improvement in technology and safety as well updates in AF management guidelines. The adoption of ultrasound-guided vascular access has led to a 2/3 decrease in procedural vascular complications. Transseptal puncture, which many physicians consider one of the most dreaded steps of the procedure, has become safer under direct visualization guided by intracardiac echo and three-dimensional mapping, using special radiofrequency wires like VersaCross? (Baylis Medical). The introduction of radiofrequency catheters with force or local impedance sensors and algorithms for lesion formation assessment have led to shorter radiofrequency application times, and along with second-generation single-shot cryoballoon ablation systems, have led to improved safety and a decrease in ablation procedure time. In addition, performing the procedures on continuous anticoagulation has proven to be safe and has led to lower periprocedural thromboembolic events. These improvements in safety, along with the multiple randomized trials proving the superior success of the ablation versus antiarrhythmic medication, have promoted the ablation as first-line therapy for both paroxysmal and persistent AF.
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