Quality of atrial fibrillation ablation: "success is not final, failure is not fatal; is it the score that matters?".

In the current issue of HeartRhythm, Chinitz et al present a novel scoring system (atrial fibrillation ablation [AFA] score) for evaluating the quality and success of catheter ablation for the treatment of paroxysmal atrial fibrillation (AF). We have paraphrased the words attributed to Sir Winston Churchill to give context to the transience of the wins and losses perceived in the greater battle against the formidable opponent of AF. We did this in order to shed light, and to pause and think of the direction AF ablation— the most prolific business in interventional electrophysiology —is taking. In their article, Chinitz et al underline the fact that a scoring system that incorporates quality and success has not been available for AF ablation and that the current use of AF recurrence as an outcome measure has limitations. The AFA score takes into account disparate factors such as lesion delivery, complications, and outcomes in order to evaluate the results and quality of AF ablation and allows for comparison of different techniques. This is achieved by incorporating 6 procedural features, half of which estimate efficacy and the other three reflect the relative acute safety of the procedure. A very strong emphasis is made on the total number of procedures performed, as seen in the relatively high score achieved by radiofrequency ablation in their article compared with emerging balloon techniques (cryo and laser), even though both redo and reconduction rates are quite similar among all methods, as seen in their Table 1. Although one would consider the novelty of this score may lie (if validated against meaningful outcomes) in its value in showing differences among manufacturers, operators, techniques, and institutions, the devil is always in the details. Like all creative concepts, this concept paper raises more questions than provides solutions to the problem at hand. What would this difference in score mean to the patient we hope to care for? The user of this score will not take into account the very premise for performing the procedure, that is, symptom relief. The score will only allow for comparison of nonpharmacologic treatment strategies that strictly target the pulmonary veins and does not permit comparison of AF