TRIAL FIBRILLATION (AF) REPresents an important public health problem. Patients with AF have an increased longterm risk of stroke, heart failure, and all-cause mortality. [1][2][3][4] Furthermore, patients with AF describe a considerably impaired quality of life (QOL) that is independent of the severity of the disease. 5,6 Restoration and maintenance of normal sinus rhythm following treat-ment directly correlates with improved QOL in these patients. [5][6][7][8] Although antiarrhythmic drugs are generally used as first-line therapy to treat patients with AF, effectiveness remains inconsistent. The likelihood of AF recurrence within 6 to 12 months approaches 50% with most drugs. [9][10][11] Antiarrhythmic drugs are also associ-ated with cumulative adverse effects over time. 1 Catheter ablation has accordingly become an alternative therapy for AF. 12 Several recent studies have See also Patient Page.

Background-Radiofrequency ablation for atrial fibrillation is becoming widely practiced. Methods and Results-Two patients undergoing circumferential pulmonary vein ablation for atrial fibrillation in different centers developed symptoms compatible with endocarditis 3 to 5 days after the procedure. Their clinical condition deteriorated rapidly, and both suffered multiple gaseous and/or septic embolic events causing cerebral and myocardial damage. One patient survived after emergency cardiac and esophageal surgery; the other died of extensive systemic embolization. An atrio-esophageal fistula was identified in both patients. Conclusions-Atrio-esophageal fistulas can occur after catheter ablation in the posterior wall of the left atrium. This diagnosis should be excluded in any patient with symptoms or signs of endocarditis after left atrial ablation, and expeditious cardiac surgery is critical if the diagnosis is confirmed. Lower power and temperature settings for applications of radiofrequency energy along the posterior left atrial wall may prevent further cases of fistula formation.

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Background-Segmental ostial catheter ablation (SOCA) to isolate the pulmonary veins (PVs) and left atrial catheter ablation (LACA) to encircle the PVs both may eliminate paroxysmal atrial fibrillation (PAF). The relative efficacy of these 2 techniques has not been directly compared. Methods and Results-Of 80 consecutive patients with symptomatic PAF (age, 52Ϯ10 years), 40 patients underwent PV isolation by SOCA and 40 patients underwent LACA to encircle the PVs. During SOCA, ostial PV potentials recorded with a ring catheter were targeted. LACA was performed by encircling the left-and right-sided PVs 1 to 2 cm from the ostia and was guided by an electroanatomic mapping system; ablation lines also were created in the mitral isthmus and posterior left atrium. The mean procedure and fluoroscopy times were 156Ϯ45 and 50Ϯ17 minutes for SOCA and 149Ϯ33 and 39Ϯ12 minutes for LACA, respectively. At 6 months, 67% of patients who underwent SOCA and 88% of patients who underwent LACA were free of symptomatic PAF when not taking antiarrhythmic drug therapy (Pϭ0.02). Among the variables of age, sex, duration and frequency of PAF, ejection fraction, left atrial size, structural heart disease, and the ablation technique, only an increased left atrial size and the SOCA technique were independent predictors of recurrent PAF. The only complication was left atrial flutter in a patient who underwent LACA. Conclusions-In patients undergoing catheter ablation for PAF, LACA to encircle the PVs is more effective than SOCA.