The role of posterior wall isolation in catheter ablation of persistent atrial fibrillation

The left atrial posterior wall has many embryologic, anatomic, and electrophysiologic characteristics, that are important for the initiation and maintenance of persistent atrial fibrillation. The left atrial posterior wall is a potential target for ablation in patients with persistent atrial fibrillation, a population in whom pulmonary vein isolation alone has resulted in unsatisfactory recurrence rates. Published clinical studies report conflicting results on the safety and efficacy of posterior wall isolation. Emerging technologies including optimized use of radiofrequency ablation, pulse field ablation, and combined endocardial/epicardial ablation may optimize approaches to posterior wall isolation and reduce the risk of injury to nearby structures such as the esophagus. Critical evaluation of future and ongoing clinical studies of posterior wall isolation requires careful scrutiny of many characteristics, including intraprocedural definition of posterior wall isolation, concomitant extrapulmonary vein ablation, and study endpoints.