Looking for new frontiers in atrial fibrillation ablation. A remaining challenge for health care

Abstract

In the last two decades, several randomized clinical trials have shown superiority of catheter ablation over antiarrhythmic drugs therapy to achieve sinus rhythm and to improve symptoms and quality of life in paroxysmal and persistent atrial fibrillation (AF) patients. 1,2 Since the first demonstrations that pulmonary veins isolation (PVI) could prevent AF initiation, catheter ablation of AF has evolved from an experimental procedure to a standard rhythm control strategy for patients with symptomatic recurrent AF, and may be appropriate to perform even as first-line therapy. 3 Despite progresses in the management of patients with AF, the prevalence of this arrhythmia in increasing worldwide and it remains one of the major causes of stroke, heart failure and cardiovascular morbidity, representing a substantial health burden for patients and societies.Catheter ablation of AF is now commonly used and is increasing markedly as a real clinical option for the treatment of this complex arrhythmia, representing around 30% of all ablations performed in Portugal. 4 However, AF recurrence can occur in 20-40% of the patients in the first year, requiring an additional catheter ablation. For persistent AF, the situation seems less clear, as the evidence base is weaker. 5 Differences in the success rates are likely E-mail address: m.martinsoliveira@gmail.com related to a more complex substrate in persistent (and long-standing persistent) AF, and with the fact that the electrical, autonomic and structural changes related to the atrial remodeling phenomena promote the maintenance of AF, contributing to the resistance to sinus rhythm conversion and to AF recurrences. 6,7 More advanced AF is, therefore, more difficult to treat with simple catheter ablation. Nevertheless, around 40% of the procedures performed are reported to be for patients with persistent type of AF. 8 This remind us that the optimal ablation technique is still to be elucidated, particularly for the treatment of persistent AF.A lot has changed in AF ablation. Knowledge regarding patients selection and follow-up, new catheters, contactforce tools, 3D mapping systems allowing high-resolution electrical analysis, integrating imaging, type of energy used and different technical approaches have evolved over the past years, reflecting the integration of multidisciplinary input of expert cardiologists, cardiac surgeons, electrophysiologists and engineering teams. However, this is a complex intervention with potential major complications and with risk of arrhythmia recurrences, frequently occurring in subjects with PV electrical reconnection. 9 Therefore, there is consensus among experts that all patients undergoing AF ablation should be seen in follow-up regularly after the ablation procedure in order to recognize potential complications and optimize outcome results. 10