The role of catheter ablation in the management of atrial fibrillation

Abstract

Atrial fi brillation is driven by spontaneous electrical activation emerging from the pulmonary veins. Catheter ablation using either radiofrequency or cryothermal energy electrically isolates these veins from the left atrium, both reducing the burden of atrial fi brillation episodes and improving the patient's symptoms. Catheter ablation is superior to antiarryhthmic drugs when patients are carefully selected. Underlying medical problems -including obesity, hypertension and obstructive sleep apnoea -should be optimally treated before considering ablation. Although this treatment has the potential to cure patients of their symptoms, they should be aware of the important associated procedural complications. IntroductionAtrial fibrillation (AF) is a massive problem in the ageing UK population, and catheter ablation offers the current generation of physicians a curative treatment strategy. A discussion of ablation requires an understanding of the electrophysiology underlying AF, so in this article we review the types and mechanisms of AF, summarise the catheter ablation technologies currently available and discuss the evidence and guidelines supporting their use. We conclude by looking at future developments for this exciting field. Types and mechanisms of AFThe natural history of AF is to progress from short paroxysms that self-terminate, to longer episodes that will not terminate spontaneously (ie are persistent) and finally to the point when the atria can no longer support sinus rhythm -ie permanent AF. The precise definitions are provided in Box 1. Longstanding persistent AF is a useful term when assessing the outcomes of AF ablation because it is associated with worse outcomes than paroxysmal AF or AF of short duration. Fig 1 summarises the mechanisms that are important in the initiation and maintenance of AF.Paroxysmal AF is initiated primarily by ectopic beats originating from the pulmonary veins, 1 although other ABSTRACTThe role of catheter ablation in the management of atrial fibrillation anatomical sites of triggers are recognised, such as the superior vena cava. 2 The pulmonary veins have unique ion channel distribution and electrophysiological properties such that automatic activity and local re-entry circuits within the muscular sleeves of these veins generate ectopic beats.3 A series of atrial ectopic beats emerging from the pulmonary veins at a high frequency (3-10 Hz) cannot be conducted across the rest of the atria in a 1:1 fashion, so electrical wavefronts break up causing activation of the atria to degenerate into a heterogeneous or chaotic pattern, easily recognised on the surface electrocardiogram as fibrillation waves. However, the long refractory periods of atrial tissue will not perpetuate these multiple wavefronts so that, when the pulmonary veins stop firing, AF terminates.An episode of AF results in electrical (and later structural) remodelling of the atrial myocardium (shortening its refractory periods) and allows for the AF to be perpetuated even when the original triggers are removed ...

RETRACTED: Wound incidence and outcomes in atrial fibrillation: Comparing catheter ablation and anti‐arrhythmic drug therapy

“…Catheter ablation, despite being progressively favoured for AF because of its efficacy in preserving sinus rhythm, was linked to the range of complications, most notably at the site of catheter insertion. 19 , 20 The catheter ablation group exhibited a greater prevalence of both minor and severe wound complications in comparison with the anti‐arrhythmic drug therapy group, according to the study. Nevertheless, these variations failed to reach statistical significance, indicating that although catheter ablation might have exhibited a propensity for heightened wound complications, it did not surpass drug therapy in terms of risk in this regard.…”

“…Catheter ablation, despite being progressively favoured for AF because of its efficacy in preserving sinus rhythm, was linked to the range of complications, most notably at the site of catheter insertion 19,20 . The catheter ablation group exhibited a greater prevalence of both minor and severe wound complications in comparison with the anti‐arrhythmic drug therapy group, according to the study.…”

Antiarrhythmic drug therapy and catheter ablation in patients with paroxysmal or persistent atrial fibrillation: a systematic review and meta-analysis

“…Catheter ablation involves using radiofrequency energy delivered to strategic locations in the left atrium to electrically isolate and ablate arrhythmogenic foci [ 10 ]. This technique aims to prevent AF triggers and maintenance [ 10 ]. Technological advancements have improved ablation success.…”