1. John R Onufer MD FHRS

2.  Paroxysmal(that which terminates spontaneously) Persistent Sustained > 7 days, or lasting < 7 days but requires pharmacologic or electrical cardioversion treatment  Long lasting persistent: That which may last longer than 7 days but plans to convert to nsr  Permanent No longer plan to return to NSR  (chronic afib is no longer a term)

3.  1. PV isolation: PV isolation alone is a 50-20% Success (afib <1 year associated with higher success)  2. Linear lesions with pv isolation (Willems: 69 vs 20% mean fu 487 days)  Roof between lspv and rspv  LIPV to Mitral annulus  TV-IVC

4.  3. CFAEs: Definition variable  120 msec. but not clearly associated with areas of scar.  Variable results  4. Non Pulmonary Foci;  Ligament of Marshall  SVC  Mitral annulus  CS  Crista terminalis  LA posterior wall  LA appendage

5.  38% Drug free success at 20 months  81% if perform multiple procedures  Termination of afib during ablation for persistent and long standing persistent afib predictive of higher success rate.  Critical to confirm pv isolation and Integrety of lines after conversion to nsr  86% terminate to atach or aflutter (focal, macro reentrant, localized reentry)

6.  Higher complication rate  Longer procedure times  Higher rate of post procedure atrial tachycardias  Longer fluro times

14.  Higher rates of recurrance:  LA size greater than 4.3 cm  Pulmonary disease  Duration of afib  Valvular heart disease

16.  Careful identification of the PV ostia is mandatory to avoid ablation within the PVs.  If a focal trigger is identified outside a PV at the time of an AF ablation procedure, ablation of that focal trigger should be considered.  If additional linear lesions are applied, operators should consider using mapping and pacing maneuvers to assess for line completeness.  Ablation of the cavotricuspid isthmus is recommended in patients with a history of typical atrial flutter or inducible cavotricuspid isthmus dependent atrial flutter.

17.  If patients with long standing persistent AF are approached, operators should consider more extensive ablations based on linear lesions or complex fractionated electrograms  It is recommended that RF power be reduced when creating lesions along the posterior wall near the esophagus

18.  1. Remains a challenge  2. There is no uniform procedure  PV antral isolation superior to pv wide area encircling lesions with voltage abatement  CFAE ablation alone inferior to PVAI and linear lesions  No incremental benefit to right atrial CFAE ablation (routinely)  CFAE ablation may or may not provide incremental benefit when added to PVAI.  3. Risk/Benefit for any patient has to be carefully considered  4. Long term outcomes need to be evaluated in randomized trials