Catheter ablation for the management of atrial fibrillation: current technical perspectives

Abstract

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice, with a prevalence that increases alongside the ageing population worldwide. The management of AF involves restoration of sinus rhythm through antiarrhythmic drug therapy. Yet, these medications have only modest efficacy in achieving long-term success, have not shown to result in a mortality benefit, are frequently not tolerated and have associated adverse side effects. Therefore, catheter ablation has become a valuable treatment approach for AF and even a viable first-line strategy in select cases. Traditionally, the combination of radiofrequency energy and a three-dimensional electroanatomical mapping system has been used to guide catheter ablation for AF. However, single-procedural efficacy and long-term outcomes still remain suboptimal for many patients, particularly those with persistent or long-standing AF. Recent advances in ablation technology and strategy, therefore, provide new procedural approaches for catheter-based treatment with the aim of overcoming current challenges in procedural duration and overall success. The aim of this paper was to provide an updated review of the current practices and techniques relating to ablation for AF and to compare the use of these strategies for paroxysmal and persistent AF.

Contemporary management of heart failure patients with reduced ejection fraction: the role of implantable devices and catheter ablation

“…Although multiple-procedure success rates of PVI in patients with AF range 50-80%, efficacy remains suboptimal in patients with persistent and long-standing persistent AF [91]. The success of ablation therefore depends on various physiological factors, including the type and duration of AF (e.g., paroxysmal versus persistent), structural heart remodelling, atrial wavelets and multiple macro re-entry circuits that complicate procedural success, in addition to insufficient lesion formation during the index procedure [92]. Innovative tools that have more recently emerged to overcome the limitations of existing ablative technology include singleshot pulmonary vein isolation modalities in the form of cryoballoon (e.g., CRYO4PERSISTENT AF trial, demonstrating a 61% single-procedure success at 12 months post-ablation) [93,94], cardiac magnetic resonance imaging-guided LA substrate modification in addition to standard PVI using cryoablation [95], laserballoon ablation (demonstrating similar efficacy as wide-area circumferential PVI using irrigated RF in persistent AF) [96], in addition to the use of markers of ablation lesion quality (e.g., ablation index) [97] and contact force-sensing technologies [98].…”

Atrial Fibrillation Ablation: When and Why?

“…This latter group has reported AFA success rates noted to be as low as 21% [26,27]. The proposed explanation is that the cardiac tissue, the organ and its performance, the substrate itself is inherently different between paroxysmal versus chronic or persistent AF [28]. Here again the above-noted paradigm may hold value.…”

“…Here again the above-noted paradigm may hold value. Traditional explanations have been that persistent AF has multiple sites of the dysrhythmia including all four PVs and their antrum [28]. Thus, PVI of a single vein area in this setting is predictably unsuccessful.…”

Role of Oxidative DNA Damage and Repair in Atrial Fibrillation and Ischemic Heart Disease

“…Currently, most of the commonly used AF treatments are focused on surgical and anti-arrhythmic pharmacotherapeutic treatments [ 14 ]. Although invasive catheter-based ablation is promising in early-stage AF, a high percentage of recurrence requires even multiple expensive procedures [ 144 ]; currently available pharmacological therapies such as amiodarone, digoxin, calcium-channel blockers, and beta-blockers are mostly symptomatic treatments, directed at rate/rhythm control [ 4 , 145 ]. They do not prevent AF progression from paroxysmal to final permanent AF and have potentially severe (fatal) side effects.…”