The ablative management of atrial fibrillation, despite a number of landmark discoveries, remains one of the most challenging fields in interventional electrophysiology. It is generally accepted that successful isolation of the pulmonary veins is a highly effective way of managing paroxysmal forms of AF. However, despite almost a decade of research into alternative lesion patterns, the solution to persistent AF remains beyond our grasp. A variety of strategies have been proposed to target key areas in the atria; these use various complex mapping systems, usually based on tailored lesion sets to try and improve outcomes. None have proven to be the golden bullet. We have investigated the role of a lesion set intended to alter the electrical properties of the posterior wall of the left atrium. Commonly known as the ‘box-set’, this pattern has shown promise in early studies and may provide some key insights into future developments. Surgical ablation using the Epicor system aims to deliver the box-set lesion, outcomes have previously been documented but each series has its limitations. In our series, very late outcomes are reported to show an 80% freedom from AF rate in patients with paroxysmal AF pre-operatively and only 20% in those with long-standing persistent forms. The reason behind this dramatic variation is explored through the invasive electrophysiologal assessment of both successful and unsuccessful cases. We report a clear correlation between the successful isolation of the posterior wall and long-term freedom from AF. Though surgical ablation may be an acceptable approach for some, the ultimate goal is a lesion set that can be delivered purely endocardially. We explore the outcome of one such empirical pattern based on the box-set concept delivered through linear catheter technology and report outcomes broadly similar to alternative patterns.

Introduction: Transseptal puncture (TSP) is challenging in patients with prior percutaneous atrial septal defect (ASD) occluder. We aimed to perform a systematic review and meta-analysis of the safety and efficacy of catheter ablation for atrial fibrillation (AF) in patients with percutaneous ASD occluder. Methods: We searched PubMed, Medline, Embase, Ovid, and Cochrane for studies reporting results of AF ablation (freedom from AF, fluoroscopy/procedure time, and complications) in patients with percutaneous ASD occluders. Results: Three studies with a total of 64 patients met inclusion criteria. The success rate of TSP was 100%. All patients (but one) underwent TSP under fluoroscopic and intracardiac echocardiography guidance. Freedom from AF was achieved in 77.7% (95% confidence interval [CI]: 65.7–86.3) patients. In the subgroup analysis, comparing septal versus device puncture, no significant difference in recurrence of AF was observed (23.07% vs. 16.66%; risk ratio: 1.18; 95% CI: 0.35–4.00; p =.79, respectively). The total fluoroscopy time was not significantly different in patients with TSP via native septum or device (43.50 vs. 70.67 min; p =.44), total procedural time was significantly longer with TSP via the closure device (237.3 vs. 180 min; p =.004) compared with the native septum. There were no device dislodgement or residual interatrial shunt during the follow-up period. Conclusion: Catheter ablation for AF in patients with prior percutaneous ASD closure device is feasible and safe with favorable long-term outcomes.

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