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Catheter Ablation For Atrial Fibrillation (Pulmonary Vein Ablation/Isolation)
Catheter ablation of the pulmonary veins.
Today catheter ablation is considered a first-line strategy choice in patients with Atrial Fibrillation and is vastly superior to using antiarrhythmic drugs first to treat Atrial Fibrillation symptoms.
A catheter ablation is performed by applying concentrated amounts of energy to small, targeted areas of heart tissues to destroy the tissue and create minute amounts of scar tissue known as a lesion. The lesion creates an barrier that stops the irregular electric signal, effectively stopping A-Fib from occurring.
Early catheter ablations (known then as Focal Ablation) were first performed in 1994 in Bordeaux, France (where I was cured of my Atrial Fibrillation in 1998). Over the past few decades, the technology has continued to evolve with rapid development of new techniques.
Worldwide, it’s estimated over 1.4 million cardiac catheter ablation procedures were performed in 2024 with Atrial fibrillation representing the largest and fastest-growing share of these treatments. The number of procedures is growing about 6%–8% a year.
Atrial Fibrillation: Best Technique for a Cure
Being “cured” of A-Fib is defined as restoring patients to “normal sinus rhythm” without dependence on any medications.
A catheter ablation, and specifically a Pulmonary Vein Ablation (PVA), is currently the best technique available for “curing” A-Fib. It is currently the only minimally invasive treatment for A-Fib which offers hope of a cure.
Pulmonary Vein Ablation techniques are achieving success rates of 70%-85% in making Paroxysmal A-Fib patients A-Fib free. With a second ablation, for Persistent A-Fib, for example, the success rates rise to over 90%.
Ablation Benefits Even If Not Cured: The other 15%-30% of catheter ablation patients, though not “cured” of A-Fib, may be significantly improved after an ablation. They may have fewer or less intense attacks of A-Fib. Medications that didn’t work before may now control the A-Fib. (But for some there may not be any noticeable improvement at all.)
VIDEO: What is Catheter Ablation? (click image to watch)
What is Catheter Ablation? Dr. Darryl Wells explains two ways catheter ablation is used to eliminate the triggers of A-Fib and how 3-dimensional mapping assists the physicians in viewing the anatomy and electric system of the heart. (2:33) By Swedish Heart & Vascular Institute. (Or, Watch on YouTube)
When Drug Therapy Fails: Why Patients Consider Catheter Ablation (3:00), and Catheter Ablation For A-Fib: What it is, How it’s Done and What Results Can Be Expected (4:00).
Catheter Ablation Procedure
Catheter inserted into the heart and through septum wall into Left Atria.
During a catheter ablation, the heart is beating and in constant motion (unlike open-heart surgeries when a heart-lung machine temporarily takes over the work of the heart and lungs).
A soft, thin, flexible, coated tube with an electrode at the tip is inserted through a large vein in your groin and moved into your heart. (The catheter is about the width of the lead in a pencil, while the vein is about the size of your little finger.)
These catheters can be inserted in both your right and left groins, and sometimes in your neck as well (for monitoring).
Catheter ablation is a relatively painless procedure, because there are no nerve endings in the smooth tissue of the heart and veins.
3D Imaging to Detect A-Fib Signals
Electrophysiologists (EPs) use Fluoroscopy, a special type of X-Ray, along with imaging systems to see inside the heart.
Sensors on specialized mapping catheters record electrical activity from multiple heart walls at once. Computer software builds a digital 3D model of your heart’s anatomy which highlights the chaotic electrical signals.
3D images of heart with inset image of sensor tip of catheter.
Location and Isolation of Atrial Fibrillation Signals
Research has shown that most A-Fib signals come from the openings (ostia) or sleeves of the four Pulmonary Veins in the left atrium.
Energy Sources: Today’s catheter devices differ by their energy source: heat (Radio Frequency), freezing (CryoBalloon) and electrical pulses (Pulsed Field Ablation).
Illustration: A left atrial pulmonary vein ostium and sleeve.
RF Energy Ablation Lesions: One technique is to make circular radiofrequency (RF) ablation lines around each pulmonary vein opening. This isolates the pulmonary veins (PVs) from the rest of the heart and prevents any pulses from these veins from getting into the heart.
Or, EPs may make one large oval lesion encircling and isolating two PVs at the same time (called Wide Area Antrum Circumferential Isolation).
Cryo Energy Ablation Lesions: Another technique to form a circular ablation uses a balloon catheter and cryo (freezing) energy to encircle the vein opening and make the circular lesions.
3D Ablation Map of heart: White dots are RF lesions. Notice the continuous line formed.
Note: Timing of your ablation is more important than the energy source used. Getting an ablation within the first 12 months after diagnosis improves outcomes, i.e., before significant remodeling can alter your heart.
Locating More A-Fib Signals: Pulmonary Vein Potentials
A different method of locating and eliminating A-Fib signals uses Pulmonary Vein Potentials. A potential is an electrical charge or energy—like the battery energy in your car. Even if your car isn’t running, you can still measure 12 volts “potential” at the battery.
Similarly, in your heart any potential in a pulmonary vein area can be measured and pinpointed, even if you aren’t in A-Fib at the time. When the area is ablated, the potential disappears.
The Final Check: Induce A-Fib/Flutter with Drugs
As a final check after the Pulmonary Vein potentials or PV triggers are isolated, the EP will try to induce A-Fib (or Flutter) by the use of drugs such as Isoproterenol or Adenosine. (Hopefully, A-Fib will not recur.) All too often other A-Fib potentials or trigger sites are found outside of the Pulmonary Veins.
These have to be tracked down, mapped, and ablated/isolated. Sometimes potentials or other areas of abnormal electrical activity are not visible during the procedure because the pulmonary vein triggers suppress or hide them. That’s why many EPs wait a half hour before proceeding to allow these potentials or possible gaps to appear.
The goal is to eliminate all these sites so that A-Fib (Flutter) can no longer be induced.
Ablation for Persistent A-Fib/Recurrent A-Fib: Looking Beyond the PVs
While it’s generally accepted that most cases of Atrial Fibrillation are triggered from inside or close to the Pulmonary Veins, alas this is not the case for many patients with Persistent A-Fib. The same is true with cases of Very Late Recurrence Atrial Fibrillation (A-Fib that recurs 5-10 or more years later after a successful catheter ablation.)
My own A-Fib returned 20 years after I was cured in 1998 in Bordeaux, France. You can read about my 2019-2021 ablations (including a Watchman) and the multiple locations of my non-PV triggers that were ablated…I have been A-Fib free since.
In 12%-20% of cases, A-Fib triggers for Persistent A-Fib and Very Late Recurrence A-Fib are found outside the pulmonary veins.
Possible locations of non–pulmonary vein triggers for atrial fibrillation
After a catheter ablation of the Pulmonary Veins, if A-Fib persists, a repeat ablation procedure will first look for and ablate any gaps in the lesions around the PVs (the heart is a resilient muscle that tries to heal the lesions). Then, the EP will seek out and ablate non-pulmonary vein triggers.
Major sources of non-pulmonary vein triggers in other areas of the heart are:
• left atrial posterior wall
• left atrial appendage
• ligament of Marshall
• coronary sinus
• superior vena cava
• crista terminalis
This type of “investigative” ablation requires a “master” electrophysiologist, someone with the experience to track down all possible sources of A-Fib signals. (For a list of these EPs, see Steve’s Directory of Doctors: Doctors Specializing in Persistent/Long-standing Persistent A-Fib.)
Types of Catheter Ablations: How They Differ
Three types of catheter ablations are available: Radiofrequency Ablation, CryoAblation and Pulsed Field Ablation.
Radiofrequency Ablation
Illustration: Radiofrequency catheter delivering RF energy.
Early Radiofrequency (RF) Ablations date back to 1994. RF Ablation is a well-established minimally-invasive cardiac procedure with decades of use to treat A-Fib.
RF Ablation uses radiofrequency energy delivered through a catheter with an electrode. The catheter applies radiofrequency waves directly to the tissue, creating a burn that destroys cells through coagulative necrosis. The catheter is highly maneuverable, allowing for precise point-by-point ablation.
RF Ablation of the Pulmonary Veins: A thin catheter is guided into the heart, then a 3D map of the heart is created. To isolate the Pulmonary Veins, RF energy is used in a point-by-point approach to form a continuous scar line. The catheter must be precisely maneuvered to apply heat around each pulmonary vein, making it time-consuming but offering more control in complex cases.
RF Ablation provides flexibility to create customized lesions beyond the pulmonary veins. It allows for highly customized scar patterns—ideal for complex cases including Persistent Atrial Fibrillation.
Complications: severe risks are uncommon; they include Atrioesophageal Fistula and Phrenic Nerve injury.
CyroAblation
Illustration: CryoBalloon catheter at PV
CryoAblation was approved for A-Fib use in December 2010. Cryoablation is best suited for simpler A-Fib cases, as its balloon shape limits lesion flexibility. It works well for Pulmonary Vein isolation but is less adaptable for targeting other areas.
CryoAblation of the Pulmonary Veins: A tiny balloon at the tip of the catheter is inflated at the opening of the Pulmonary Veins. The balloon shapes to the tissue, creating a steady, uniform circular block in a single application. Cold coolant gas chills the balloon, freezing and disabling the surrounding tissue to form a continuous scar line.
With Cryoballoon catheters, EPs can temporarily cool tissue to check placement (with an option to reverse) before freezing it permanently. Unlike RF ablation “burns” that can crust, fall off and lead to a blood clot (that’s why blood thinners like heparin are used to avoid this), with CryoAblation tissue freezing this doesn’t happen. There is less risk of damaging other areas of the heart or esophagus. Generally, procedure times are shorter than RF ablations.
The main complication of CryoAblation is a temporary palsy of the phrenic nerve.
CyroAblation/RF Ablation Combined for Persistent A-Fib: Some centers first use Cryoballoon catheters to isolate the Pulmonary Veins with uniform, circular lesions, then use RF catheters (or non-balloon Cryo catheters) to make linear lesions to target other areas of the heart.
Pulsed Field Ablation
Illustration: PFA catheter from FARAPULSE™ in flower mode.
Pulsed Field Ablation is widely approved and used in Europe beginning in 2021. U.S. trials began in 2019 with FDA approval in 2024. There are five FDA-approved Pulsed Field Ablation systems (with differing catheter configurations).
What makes it different? Pulsed Field Ablation uses a fundamentally different process to ablate heart tissue. An instantaneous electrical field (irreversible electroporation) is applied and the cell dies (there is no charring or crust formation) and the cell remains intact. PFA makes a long-lasting lesion in a matter of seconds vs RF and Cryo (60 seconds–150 seconds per lesion).
Pulsed Field Ablation of Pulmonary Veins and Other Areas
A typical Pulsed Field Ablation, for example, using the FARAPULSE™ PFA System involves positioning the unique catheter with electrodes convertible from a “basket” configuration, then a “flower” configuration.
Each Pulmonary Vein opening receives paired energy deliveries, first with the “basket” configuration, then with the “flower” configuration. Then they are rotated, for a total of eight applications per vein to complete and ensure electric field penetration.
The same technique can be used in other areas of the heart, i.e., ablating the Posterior Wall of the Left Atrium. Or, in the right atrium, for example, making a Cavo-Tricuspid Isthmus line to ablate Flutter.
The PFA process is “tissue selective” meaning the signal doesn’t affect other surrounding non-heart tissue such as the esophagus or phrenic nerve making PFA much safer than other ablation energy sources.
Procedural times are usually 1–3 hours for PFA versus 3–5 hours for RF and Cryo Catheter Ablations.
For a full description of PFA, see Pulsed Field Ablation—Groundbreaking Innovation in Atrial Fibrillation!
Summary: Types of Catheter Ablation
Radiofrequency Ablation and CryoAblation each offer unique benefits and limitations when treating Atrial Fibrillation. These differences influence the choice of method based on patient needs and case complexity.
Both reliably achieve Pulmonary Vein isolation. Complications for both involve the non-selective nature of injury from thermal energies (RF and Cyro).
Pulsed Field Ablation introduces a fundamentally different approach based on irreversible electroporation enabling rapid lesion formation with relative protection of surrounding tissues. Contemporary randomized trials demonstrate results comparable to Radiofrequency and CryoAblation, along with effectiveness and a favorable safety profile.
As a relatively new procedure, Pulsed Field Ablation will continue to evolve alongside the established thermal techniques of Radiofrequency Ablation and CryoAblation.
Permanently A-Fib Free?
Catheter Ablation is currently the only minimally-invasive strategy offering the hope of becoming A-Fib free permanently. (The various Maze surgeries successfully treat A-Fib but are usually done concurrent with other open-heart surgeries.)
Other factors can influence whether you stay A-Fib free after a “successful” catheter ablation.
Early Treatment: Research from the Mayo Clinic shows that having an ablation within one year of your initial A-Fib diagnosis significantly cuts down the risk of your A-Fib returning.
Lifestyle Changes: Addressing obesity, smoking, lack of exercise and alcohol intake will help keep the heart in a normal rhythm long-term. For more, see my article about Lifestyle Choices and What You Can Do.
Managing Comorbidities: Most A-Fib patients have at least one concurrent medical condition (e.g., hypertension, diabetes, sleep apnea) that makes treating A-Fib more difficult and can have a direct effect on maintenance of normal sinus rhythm after a catheter ablation. For more, see my article about Comorbid Risks.
Recurrence: A “successful” ablation though, may not be permanent. The problem is called recurrence (or reconduction). Heart tissue is very hardy. Over time ablation scars can heal over and allow A-Fib signals to again disrupt the heart.
But other factors strongly influence if your A-Fib recurs. Recurrence is influenced by an enlarged heart, development of fibrosis and progression to Persistent A-Fib or Long-Standing Persistent A-Fib.
All these predictors are influenced by how long and how far your A-Fib has progressed. This underlines the importance of early treatment with catheter ablation rather than later.
If recurrence occurs, a “touch-up” catheter ablation can increase your odds of a cure by up to 90% (see my A-Fib story for my recurrence after 20 years and my return to a life free of A-Fib).
Find the Best EP for Your type of A-Fib
The success of your catheter ablation often depends on the skill, techniques, and experience of the electrophysiologist (EP.)
Don’t just go to an EP because they are near you. Go to the best you can find and reasonably afford to travel to.
To find the right doctor and electrophysiologist for you and your treatment goals, go to our page, Finding the Right Doctor for You and Your A-Fib.
Since catheter ablation has become a first-line strategy choice for Atrial Fibrillation, the number of heart centers in the U.S. performing catheter ablations for A-Fib has steadily grown (the number of international centers has increased as well.)
For help finding EPs treating Atrial Fibrillation patients, see Steve’s Directory of Doctors Treating A-Fib: Medical Centers and Practices.
For surgical options for treating Atrial Fibrillation, see The Cox-Maze & Mini-Maze Surgeries and the Hybrid Surgery/Ablation.
If you find any errors on this page, email us. Y Last updated: Monday, August 31, 2026
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