Progress Continues in Our Quest to Cure All Types of Cardiac Arrhythmias with Catheter Ablation

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Correspondence Details:Hugh Calkins, Professor of Medicine, Director of Electrophysiology, Johns Hopkins Medical Institutions, Baltimore, MD. E:

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I am pleased to be appointed as AER’s section editor for Clinical Electrophysiology and Ablation.

I look forward to working with authors from throughout the world to put together insightful articles that help clinical electrophysiologists globally to keep up with our rapidly advancing field. From my perspective, the only thing that remains constant in our field is continued progress and change. Together, we are working to continuously improve the techniques and outcomes of catheter ablation.

After graduating from my cardiology and electrophysiology fellowship at Johns Hopkins, I was fortunate to get a faculty position at the University of Michigan working with Dr Fred Morady. At that point in time radiofrequency (RF) energy had not been identified as an energy source for catheter ablation; direct current (DC) shock ablation, performed under general anaesthesia, was the standard approach for catheter ablation. Moreover, the only arrhythmias that were targets for ablation were ventricular tachycardia, posteroseptal accessory pathways and the atrioventricular (AV) node. The shift to RF energy occurred in 1989 during my first year on faculty at the University of Michigan. It was quickly determined that accessory pathways in all locations could be targeted for ablation, as well as ventricular tachycardia (VT) and the AV node. The next arrhythmia to emerge as a target was AV node re-entry. At first, a fast pathway approach was used. Several years later it was recognised that the posterior approach was associated with improved outcomes.

Catheter ablation of atrial flutter was not being performed in 1989 as the re-entry circuit was not fully understood. It was in the early 1990s that the re-entry circuit for typical atrial flutter was determined and, as a result, ablation of this arrhythmia became possible. By the mid 1990s the electrophysiology community was starting to focus on catheter ablation of atrial fibrillation. It was initially believed that ablation in the left atrium was too high risk. But pioneering electrophysiologists helped us move past this barrier. And of course the big breakthrough was identification of the pulmonary veins as the most common site of triggering of atrial fibrillation and also recognition of the importance of an ablation strategy guided by electroanatomic mapping. These seminal discoveries have paved the way for catheter ablation of atrial fibrillation to emerge as a safe and effective ablation procedure.

While great progress has been made, much work lies ahead. While for many types of cardiac arrhythmias catheter ablation is a highly efficacious and safe ablation procedure, with little room for further improvement (atrial flutter, accessory pathways, the AV node, premature ventricular contractions (PVCs)), the outcomes of catheter ablation for more complex arrhythmias are modest.

High on the list of unmet challenges are catheter ablation of atrial fibrillation and, in particular, persistent atrial fibrillation, catheter ablation of VT in structural heart disease, and catheter ablation of ventricular fibrillation. I remain optimistic that over the next decade we will dramatically improve the outcomes of ablation for these more complex arrhythmias. As progress is made, you can count on AER to provide insightful articles that will keep us all up to date and moving ahead in the rapidly progressing field of Clinical Electrophysiology and Ablation.