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Atrial fibrillation is the most common clinical arrhythmia, affecting millions of people worldwide and utilizing billions of dollars annually in heath care costs associated with the disease. Catheter based ablation, centering around the electrical isolation of the pulmonary veins, has emerged as a viable treatment option for patients with symptomatic paroxysmal or persistent atrial fibrillation. Because of the complex nature of the procedure, there are a number of potential complications which can occur which are related to problems with vascular access, mechanical complications resulting from catheter manipulation within the heart, cardioembolic complications, and complications arising from the effects of radiofrequency ablations in the left atrium. The most frequent complications arise from pseudoaneurysms, arterio-venous fistulas, hematomas, neurologic events (stroke and transient ischemic attacks), and pericardial effusion/tamponade. An evolving understanding of the risks of the procedure have helped to minimize complications by changing ablation strategies to avoid lesion delivery within the veins, emphasizing careful attention during the procedure to anticoagulation, utilizing intracardiac ultrasound and electroanatomic mapping systems for better visualization of intracardiac structures, and recognizing complications promptly during and after the procedure. Hopefully, improved techniques in the future will help to further improve the safety of catheter ablation of atrial fibrillation to allow for continued growth of this procedure.

Ablation to eliminate atrial fibrillation (AF) is a therapy in evolution. Approaches to the ablation appear to be currently divided into 2 major strategies anatomic versus electrically guided. In addition in using an electrically guided techniques debate remains whether a targeted approach should be used, whether exit block should be documented, and whether all non pulmonary vein triggers should be targeted. This review highlights the different ablation strategies and identifies a systematic approach to ablation of pulmonary and non pulmonary vein triggers that we have adapted at our institution. The role of intracardiac echo, trigger provocation and localization and the use of 3-D mapping systems in AF ablation are defined.