Atrial fibrillation (AF) is a major health problem, affecting 1-2% of the population. AF reduces quality of life (QoL) and increases morbidity and mortality. Catheter ablation (CA) is the most efficacious means of restoring sinus rhythm but is not always successful and is occasionally associated with serious complications. Several questions are currently unanswered. True procedural effectiveness, particularly long-term, remains uncertain, especially in more advanced disease. The best technique for achieving success remains an issue of considerable debate and as yet, few, if any, means exist to predict when acute electrical success will translate into sustained clinical benefit. CA is indicated for symptomatic relief but QoL, both as a treatment outcome and as a guide to patient selection, has generally been overlooked in the published literature. Finally, although the maxim, “First, do no harm” may often be ascribed erroneously to Hippocrates, it remains a central tenet of medical practice. However, little previous research has focussed on improving the safety of CA.
I have attempted to tackle these issues from a number of angles. I have performed a comprehensive literature review and a retrospective analysis of ablation outcomes at Liverpool Heart and Chest Hospital, the largest and longest such data from the UK, to ascertain a comprehensive, up-to-date assessment of practice. In an effort to improve procedural success, I carried out a multicentre randomised controlled trial testing two ablation strategies. A sub-study tests the hypothesis that clinical outcomes can be predicted by a novel measure of effective ablation. Two further studies aim to improve safety, through use of ultrasound to guide venous access, and to better understand QoL in AF – a theme throughout the thesis – which may help improve selection of appropriate patients for CA. Together, I hope these studies will help physicians improve the outcomes of CA for their patients.