Understanding the Electrical Substrates Contributing to "Ablation-Resistant" Atrial Fibrillation?

Atrial fibrillation (AF) was largely ignored by cardiac electrophysiologists until it was first suggested in 1998 that it might be amenable to catheter ablation. In the 25 years since then, a vast body of knowledge has emerged, initially reporting the "hypes and hopes" that ablation was appropriate for all but more recently acknowledging that not all patients benefit from this approach. The AF "epidemic" and more holistic understanding of the complex contributors to its development question whether it is even meaningful to consider AF a single condition that is always responsive to ablation management. In this issue, Masuda et al¹¹ provide novel insights into the electrophysiologic "footprints" that they found in the body of the left atrium of patients who underwent a second ablation procedure after achieving pulmonary vein isolation. In conclusion, the findings require prospective validation but may show a way of achieving antiarrhythmic success in a cohort of patients responding unpredictably to current ablation strategies.