Dr Andrea Natale (St David's Medical Center, Austin, TX, US) joins us to discuss advanced strategies for atrial fibrillation ablation in challenging patient populations, offering a high-volume operator's perspective on optimising procedural success in contemporary practice.

Atrial fibrillation ablation has undergone considerable evolution in recent years, with advances in energy modalities, mapping technologies, and patient selection refining the approach to pulmonary vein isolation and beyond. Yet complex patients — those with persistent or long-standing persistent AF, structural heart disease, prior ablation failure, or significant comorbidity — continue to present meaningful clinical and technical challenges. For high-volume centres, developing reproducible strategies to maximise durable outcomes in this cohort remains a central priority.

In this interview, Dr Natale draws on extensive procedural experience to address the key decision points, technical considerations, and evolving evidence shaping AF ablation practice in 2026.

Interview Questions:

1. How do you define "complex" in the context of AF ablation, and how has this patient profile shifted in recent years?
2. What is your current ablation strategy for persistent and long-standing persistent AF, and how do you individualise beyond PVI?
3. How has the arrival of PFA influenced your approach across different patient subgroups?
4. How do you manage patients presenting for repeat ablation following prior procedural failure?
5. What role does pre-procedural imaging and mapping play in your planning for complex cases?
6. How do you approach AF ablation in patients with structural heart disease or significantly reduced ejection fraction?
7. What metrics do you use to define and audit success at a high-volume centre, and how do you sustain quality at scale?
8. What are your key take-home messages for electrophysiologists looking to optimise AF ablation outcomes in complex patients in 2026?

Recorded on-site at HRS 2025, Chicago.
Editors: Jordan Rance
Videographer:
Support: This is an independent interview produced by Radcliffe Cardiology.