{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T02:16:52Z","timestamp":1760149012199,"version":"build-2065373602"},"reference-count":36,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2023,6,27]],"date-time":"2023-06-27T00:00:00Z","timestamp":1687824000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCDD"],"abstract":"<jats:p>Atrial fibrillation is a diverse clinical entity, with persistent atrial fibrillation (PeAF) being particularly challenging to manage. Through this paper, we discuss notable developments in our understanding of ablative strategies for managing PeAF, with a special focus on posterior wall isolation (PWI).<\/jats:p>","DOI":"10.3390\/jcdd10070273","type":"journal-article","created":{"date-parts":[[2023,6,27]],"date-time":"2023-06-27T01:49:21Z","timestamp":1687830561000},"page":"273","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Ablative Management of Persistent Atrial Fibrillation (PeAF) with Posterior Wall Isolation (PWI): Where Do We Stand?"],"prefix":"10.3390","volume":"10","author":[{"given":"Omar","family":"Baqal","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, Mayo Clinic, Phoenix, AZ 85054, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2470-2862","authenticated-orcid":false,"given":"Hicham Z.","family":"El Masry","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2023,6,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1056\/NEJMoa2029554","article-title":"Cryoballoon ablation as initial therapy for atrial fibrillation","volume":"384","author":"Wazni","year":"2021","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1305","DOI":"10.1056\/NEJMoa2019422","article-title":"Early rhythm-control therapy in patients with atrial fibrillation","volume":"383","author":"Kirchhof","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"801","DOI":"10.1113\/jphysiol.2003.046417","article-title":"Cellular electrophysiology of canine pulmonary vein cardiomyocytes: Action potential and ionic current properties","volume":"551 Pt. 3","author":"Ehrlich","year":"2003","journal-title":"J. Physiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e275","DOI":"10.1016\/j.hrthm.2017.05.012","article-title":"2017 HRS\/EHRA\/ECAS\/APHRS\/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation","volume":"14","author":"Calkins","year":"2017","journal-title":"Heart Rhythm"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1394","DOI":"10.1111\/jce.14480","article-title":"Clinical outcomes of adjunctive posterior wall isolation in persistent atrial fibrillation: A meta-analysis","volume":"31","author":"Salih","year":"2020","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.1093\/europace\/euac005","article-title":"Does isolation of the left atrial posterior wall using cryoballoon ablation improve clinical outcomes in patients with persistent atrial fibrillation? 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Electrophysiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1016\/j.hrthm.2015.08.019","article-title":"Proven isolation of the pulmonary vein antrum with or without left atrial posterior wall isolation in patients with persistent atrial fibrillation","volume":"13","author":"Bai","year":"2016","journal-title":"Heart Rhythm"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1016\/j.ijcard.2014.12.035","article-title":"Does isolation of the left atrial posterior wall improve clinical outcomes after radiofrequency catheter ablation for persistent atrial fibrillation? A prospective randomized clinical trial","volume":"181","author":"Kim","year":"2015","journal-title":"Int. J. Cardiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1007\/s10840-015-0024-2","article-title":"Clinical outcome when left atrial posterior wall box isolation is included as a catheter ablation strategy in patients with persistent atrial fibrillation","volume":"44","author":"Hensey","year":"2015","journal-title":"J. Interv. Card. Electrophysiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1002\/joa3.12698","article-title":"The efficacy of posterior wall isolation in atrial fibrillation ablation: A systematic review and meta-analysis of randomized controlled trials","volume":"38","author":"Kanitsoraphan","year":"2022","journal-title":"J. Arrhythm."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"605","DOI":"10.1016\/j.jacep.2022.02.001","article-title":"Adjunctive Left Atrial Posterior Wall Isolation in Treating Atrial Fibrillation: Insight from a Large Secondary Analysis","volume":"8","author":"Jiang","year":"2022","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1001\/jama.2022.23722","article-title":"Effect of catheter ablation using pulmonary vein isolation with vs without posterior left atrial wall isolation on atrial arrhythmia recurrence in patients with persistent atrial fibrillation: The CAPLA randomized clinical trial","volume":"329","author":"Kistler","year":"2023","journal-title":"JAMA"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1812","DOI":"10.1056\/NEJMoa1408288","article-title":"Approaches to catheter ablation for persistent atrial fibrillation","volume":"372","author":"Verma","year":"2015","journal-title":"N. Engl. J. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1148","DOI":"10.1093\/ije\/dyn065","article-title":"Sensitivity of between-study heterogeneity in meta-analysis: Proposed metrics and empirical evaluation","volume":"37","author":"Patsopoulos","year":"2008","journal-title":"Int. J. Epidemiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1161\/CIRCEP.114.001943","article-title":"Five-year outcome of catheter ablation of persistent atrial fibrillation using termination of atrial fibrillation as a procedural endpoint","volume":"8","author":"Scherr","year":"2015","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1921","DOI":"10.1016\/j.jacc.2012.04.060","article-title":"Catheter ablation of long-standing persistent atrial fibrillation: 5-year outcomes of the Hamburg Sequential Ablation Strategy","volume":"60","author":"Tilz","year":"2012","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_18","first-page":"mmcts.2007.002758","article-title":"The Cox-Maze IV procedure for lone atrial fibrillation","volume":"2007","author":"Damiano","year":"2007","journal-title":"Multimed. Man. Cardiothorac. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1016\/S1043-0679(00)70020-7","article-title":"New surgical and catheter-based modifications of the Maze procedure","volume":"12","author":"Cox","year":"2000","journal-title":"Semin. Thorac. Cardiovasc. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.ipej.2019.12.001","article-title":"Comparison between surgical and catheter based ablation in atrial fibrillation, should surgical based ablation be implemented as first line? A meta-analysis of studies","volume":"20","author":"Yonas","year":"2020","journal-title":"Indian Pacing Electrophysiol. J."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2152","DOI":"10.1111\/jce.15617","article-title":"Surgical versus catheter ablation in atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials","volume":"33","author":"Rattanawong","year":"2022","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1016\/j.ijcard.2018.11.127","article-title":"Persistent atrial fibrillation: A systematic review and meta-analysis of invasive strategies","volume":"278","author":"Berger","year":"2019","journal-title":"Int. J. Cardiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"4471","DOI":"10.1093\/eurheartj\/ehaa658","article-title":"Catheter ablation vs. thoracoscopic surgical ablation in long-standing persistent atrial fibrillation: CASA-AF randomized controlled trial","volume":"41","author":"Haldar","year":"2020","journal-title":"Eur. Heart J."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e006182","DOI":"10.1161\/CIRCEP.118.006182","article-title":"Randomized Controlled Trial of Surgical Versus Catheter Ablation for Paroxysmal and Early Persistent Atrial Fibrillation","volume":"11","author":"Adiyaman","year":"2018","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1046","DOI":"10.1093\/eurheartj\/ehq079","article-title":"Drugs vs. ablation for the treatment of atrial fibrillation: The evidence supporting catheter ablation","volume":"31","author":"Nault","year":"2010","journal-title":"Eur. Heart J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e009110","DOI":"10.1161\/CIRCEP.120.009110","article-title":"Endocardial-Epicardial Dissociation in Persistent Atrial Fibrillation: Driver or Bystander Activation Pattern?","volume":"13","author":"Aronis","year":"2020","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e008512","DOI":"10.1161\/CIRCEP.120.008512","article-title":"Endocardial-Epicardial Phase Mapping of Prolonged Persistent Atrial Fibrillation Recordings: High Prevalence of Dissociated Activation Patterns","volume":"13","author":"Parameswaran","year":"2020","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e009288","DOI":"10.1161\/CIRCEP.120.009288","article-title":"Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation: Results of CONVERGE Clinical Trial","volume":"13","author":"Delurgio","year":"2020","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Van der Heijden, C.A., Webernd\u00f6rfer, V., Vroomen, M., Luermans, J.G., Chaldoupi, S.-M., Bidar, E., Vernooy, K., Maessen, J.G., Pison, L., and van Kuijk, S.M. (2023). Hybrid Ablation Versus Repeated Catheter Ablation in Persistent Atrial Fibrillation: A Randomized Controlled Trial. JACC Clin. Electrophysiol, published online ahead of print.","DOI":"10.1016\/j.jacep.2022.12.011"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1016\/j.hroo.2022.05.006","article-title":"Hybrid Convergent ablation for atrial fibrillation: A systematic review and meta-analysis","volume":"3","author":"Shrestha","year":"2022","journal-title":"Heart Rhythm O2"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Huo, Y., Gaspar, T., Sch\u00f6nbauer, R., W\u00f3jcik, M., Fiedler, L., Roithinger, F.X., Martinek, M., P\u00fcrerfellner, H., Kirstein, B., and Richter, U. (2022). Low-voltage myocardium-guided ablation trial of persistent atrial fibrillation. NEJM Evid., 1.","DOI":"10.1056\/EVIDoa2200141"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"3176","DOI":"10.1161\/01.CIR.0000074206.52056.2D","article-title":"Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy","volume":"107","author":"Lin","year":"2003","journal-title":"Circulation"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"733","DOI":"10.1161\/01.CIR.0000048140.31785.02","article-title":"Characterization of left atrial activation in the intact human heart","volume":"107","author":"Markides","year":"2003","journal-title":"Circulation"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"856","DOI":"10.1016\/j.jacc.2007.11.037","article-title":"Anatomically determined functional conduction delay in the posterior left atrium relationship to structural heart disease","volume":"51","author":"Stevenson","year":"2008","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1111\/jce.13397","article-title":"How to perform posterior wall isolation in catheter ablation for atrial fibrillation","volume":"29","author":"Sugumar","year":"2018","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1016\/j.hrthm.2020.11.008","article-title":"Epicardial course of the septopulmonary bundle: Anatomical considerations and clinical implications for roof line completion","volume":"18","author":"Pambrun","year":"2021","journal-title":"Heart Rhythm"}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/10\/7\/273\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T20:01:29Z","timestamp":1760126489000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/10\/7\/273"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,6,27]]},"references-count":36,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2023,7]]}},"alternative-id":["jcdd10070273"],"URL":"https:\/\/doi.org\/10.3390\/jcdd10070273","relation":{},"ISSN":["2308-3425"],"issn-type":[{"type":"electronic","value":"2308-3425"}],"subject":[],"published":{"date-parts":[[2023,6,27]]}}}