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  • Review Article
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Update on atrial fibrillation catheter ablation technologies and techniques

Nature Reviews Cardiology volume 10, pages 599–612 (2013)Cite this article

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Abstract

Catheter ablation of atrial fibrillation (AF) has become an important treatment method. Electrical isolation of the pulmonary veins is the cornerstone of most AF ablation procedures, and is defined by an entrance block observed on a circular multipolar electrode catheter. The safety and efficacy of AF ablation is best established in middle-aged patients with paroxysmal AF. Current guidelines recommend AF ablation with a level Ia indication in this group of patients. The long-term efficacy of AF ablation is well established in patients with paroxysmal AF, but less so in patients with longstanding persistent AF. In this population, current guidelines recommend AF ablation with a level IIb indication. The efficacy of catheter ablation in other patient populations, particularly elderly people and those with concomitant conditions, is also poorly defined. AF ablation is reasonably effective and safe at 12 months of follow-up, but recurrence of AF ≥1 year after ablation is not uncommon. Fortunately, the techniques and tools used for AF ablation continue to evolve. These developments include novel ablation catheters designed to increase safety, efficacy, and precision of the procedure, ablation strategies to target both pulmonary vein and nonpulmonary vein AF triggers, and improved imaging and electrical mapping to guide ablation procedures.

Key Points

  • Atrial fibrillation (AF) is commonly treated with catheter ablation, which aims to electrically isolate the pulmonary veins

  • Irrigated radiofrequency and cryoballon ablation catheters are the two most-commonly used tools for AF ablation

  • Robotic systems and novel catheters could improve safety and decrease the procedure duration

  • MRI-guided systems are being developed that might help define the optimal lesion ablation set in a given patient, or for real-time imaging during catheter ablation

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Figure 1: Radiofrequency ablation of atrial fibrillation.
Figure 2: Right and left anterior oblique projections of selected pulmonary vein angiograms.
Figure 3: Branching pattern of PV anatomy in patients with AF and control individuals.
Figure 4: A schematic of occlusion of the pulmonary vein with the Arctic Front® cardiac cryoablation catheter system (Medtronic Inc., Minneapolis, MN, USA).
Figure 5: HeartLight® (CardioFocus Inc., Marlborough, MA, USA) balloon showing perpendicular projection of 30° therapeutic beam of light.
Figure 6: The pulmonary vein ablation catheter (PVAC) (Medtronic Inc., Minneapolis, MN, USA) is a multielectrode ablation catheter that can be used to map, ablate, and verify isolation of pulmonary veins during an ablation procedure.
Figure 7: Stability of complex fractionated atrial electrograms.
Figure 8: Co-registered scar and voltage electro-anatomic map of the left atrium.

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Acknowledgements

The Johns Hopkins Atrial Fibrillation Program is supported by the Dr Francis P. Chiaramonte Private Foundation, the Marvin Weiner Family Foundation, and the Louise or Norbert Grunwald Endowment. The authors thank Bernadette Barcelon for help in acquiring some of the images used in this Review.

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  1. Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Sheikh Zayed Tower, Room 7125R, 1800 Orleans Street, Baltimore, 21287, MD, USA

    Jane Dewire & Hugh Calkins

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J. Dewire and H. Calkins researched data for the article, discussed the content, and reviewed and edited the manuscript. J. Dewire wrote the article.

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Correspondence to Hugh Calkins.

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Dewire, J., Calkins, H. Update on atrial fibrillation catheter ablation technologies and techniques. Nat Rev Cardiol 10, 599–612 (2013). https://doi.org/10.1038/nrcardio.2013.121

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