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ICE-guided pulmonary vein antrum isolation seems to prevent cerebrovascular accidents in patients with symptomatic drug-refractory AF who are not receiving anticoagulation therapy. ICE-guided pulmonary vein antrum isolation is an effective and safe treatment for AF.

Albeit almost an extinct complication in high-volume and experienced centres, PV stenosis most likely will continue to be a feared complication of AF ablative procedures, as they are more often performed in community settings by less-experienced operators. Severe PV stenosis is associated with a variety of respiratory symptoms that frequently mimic more common heart and lung diseases. A high degree of suspicion is necessary to avoid misleading diagnostic procedures and allow proper and prompt management of these patients.

PV dilatation is the treatment of choice for symptomatic patients but is still associated with a frequent need for repeat interventions due to restenosis. It remains to be seen whether the use of drug-coated stents will provide long-lasting results. Emphasis should be placed on prevention and imaging modalities that help to accurately delineate the PV-LA junction and guide power titration, both of which appear to provide the best means to avoid PV injury by RF energy.

The literature on ablation for AF has many of the features of clinical research in the era preceding evidence-based medicine and randomised trials. Many studies emanate from single centres, involve low patient numbers, and fail to provide adequate statistical analysis, including intention to treat analysis and evaluation of statistical power. As was the case with Maze operations, new procedures are continually proposed without completing satisfactory evaluations of previously proposed procedures. Very worrisome is that most studies have not involved neutral committees for the recording and supervision of severe complications.

The belief that AF ablation now represents a standard or, indeed, first-line treatment is excessively optimistic and may reflect occupational and economic factors encouraging mechanistic invasive procedures.

Atrial and dual defibrillators held great promise when they were introduced in the 1990s.

The devices are effective and safe in selected patients. Tolerability and acceptance by patients is good in the short term but only moderate in the longer term. The complication rate is relatively low. However, advances in ablation techniques for the treatment of atrial fibrillation have limited and will continue to limit the use of implantable atrial defibrillators. In combination with ICDs they may find a continued role in a patient group that should be further defined.

Disturbances in autonomic function can result in a wide variety of conditions that may ultimately culminate in the loss of consciousness. Success in identification of genes conferring susceptibility to hypotension and its clinical sequelae is expected to provide new insights into the pathophysiology of this condition and lead to development of highly accurate genetic tests, permitting identification of subjects with specific inherited susceptibility. These insights may permit intervention at preclinical stages with therapies tailored to underlying primary abnormalities, improving efficacy of treatment (nowadays, mostly empirical), and reducing morbidity from these diseases.

TEE is a useful tool to investigate patients undergoing ablation therapy of atrial fibrillation. The technique provides important information about the presence of thrombus and SEC in the left atrium and LAa, and about minor IAS abnormalities, which seem to occur more frequently than in the normal population. Such information is necessary for planning the approach to the PV by catheters that must cross the septum and the atrial cavity.

After ablation, TEE can be used to monitor possible minor complications, such as a residual IAS shunt or pericardial effusion. It also allows the detection of PV stenosis, a rare but dreaded complication of PVAI. A control TEE examination 3 months after the ablation procedure is probably adequate for this purpose.

ICE-guided pulmonary vein antrum isolation seems to prevent cerebrovascular accidents in patients with symptomatic drug-refractory AF who are not receiving anticoagulation therapy. ICE-guided pulmonary vein antrum isolation is an effective and safe treatment for AF.

In patients with structurally normal hearts and unexplained syncope or cardiac arrest, Brugada syndrome is considered a frequent underlying condition. In patients with suspected Brugada syndrome but inconclusive or normal ECG findings at baseline, drug challenge with intravenous administration of sodium channel blockers according to a standardised protocol is a powerful tool to unmask diagnostic type-1 Brugada ECG features and thereby identify patients at risk of sudden death. The additional impact of drug challenge in the risk stratification algorithms of patients already diagnosed with Brugada syndrome is less well-established and requires additional studies.

The literature on ablation for AF has many of the features of clinical research in the era preceding evidence-based medicine and randomised trials. Many studies emanate from single centres, involve low patient numbers, and fail to provide adequate statistical analysis, including intention to treat analysis and evaluation of statistical power. As was the case with Maze operations, new procedures are continually proposed without completing satisfactory evaluations of previously proposed procedures. Very worrisome is that most studies have not involved neutral committees for the recording and supervision of severe complications.

The belief that AF ablation now represents a standard or, indeed, first-line treatment is excessively optimistic and may reflect occupational and economic factors encouraging mechanistic invasive procedures.

The literature on ablation for AF has many of the features of clinical research in the era preceding evidence-based medicine and randomised trials. Many studies emanate from single centres, involve low patient numbers, and fail to provide adequate statistical analysis, including intention to treat analysis and evaluation of statistical power. As was the case with Maze operations, new procedures are continually proposed without completing satisfactory evaluations of previously proposed procedures. Very worrisome is that most studies have not involved neutral committees for the recording and supervision of severe complications.

The belief that AF ablation now represents a standard or, indeed, first-line treatment is excessively optimistic and may reflect occupational and economic factors encouraging mechanistic invasive procedures.