Standard procedure	Right heart catheterization via a femoral vein approach with subsequent trans-septal access to the left atrium and PVs. The cornerstone of AF ablation is the electrical isolation of the PVs. Other targets of ablation include focal triggers outside the veins (if identified), cavotricuspid isthmus (if typical atrial flutter is documented), complex fractionated atrial electrograms (areas of diseased myocardium which can perpetuate AF), and linear lines across the left atrium (left atrial roof, mitral isthmus, ligament of Marshall). Ablation is performed with either focal radiofrequency energy or cryothermal energy via a balloon catheter. Concomitant imaging modalities include left atrial angiography, intracardiac echocardiography, 3-dimensional electroanatomic mapping, and fluoroscopy.
Contraindications	Left atrial thrombus, inability to tolerate anticoagulation during and post-procedure for at least two months, poor cardiac reserve (critical coronary artery disease, decompensated heart failure, severe aortic stenosis, severe pulmonary hypertension), need for cardiac surgery for another reason during which surgical ablation/Maze can be performed
Complications	Minor: groin bleeding, hematoma, infection, pseudo-aneurysm (<1%)
	Major: stroke or TIA (0–7%), PV stenosis (1.3%), phrenic nerve paralysis (<1%), cardiac tamponade/perforation (1.2–1.5%), aorto-esophageal fistula (0.1–0.25%), death (0.1%)
Special points	Pre-procedure cardiac CT or MRI to define PV anatomy.
	Pre-procedure transesophageal echocardiography to rule out thrombus in high-risk patients (generally CHADS2 score >2).
Cost/cost-effectiveness	One study formally analyzed the cost-effectiveness of catheter ablation compared to amiodarone therapy and a rate-control strategy, finding that the incremental costeffectiveness of catheter ablation varied widely ($28,700 to $98,900 per quality-adjusted life-year) depending on the age of the patient and the baseline risk of stroke [52]. Of note, the study assumed that successful ablation of AF eliminates the excess risk of stroke, which is yet to be proven in prospective studies. The limited data on cost-effectiveness suggests that catheter ablation of AF may be cost-effective in patients with one or more risk factors for stroke but not in patients without any risk factors.