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Atrial fibrillation ablation: a realistic alternative to pharmacologic therapy

Nature Clinical Practice Cardiovascular Medicine volume 2, pages 608–609 (2005)Cite this article

The rise in hospital admission rates for atrial fibrillation (AF) among elderly patients worldwide is striking. Rate control can improve quality of life, but does not improve survival or stroke prevention. The continuing high mortality associated with AF and the failure of antiarrhythmic drugs to maintain sinus rhythm have led to a rapid increase in the number of catheter ablation procedures for AF since 1995. Over this relatively short period of time, several new catheter-based strategies have dramatically increased our knowledge of the pathophysiology of this arrhythmia and, most importantly, have demonstrated that AF is a treatable condition. In this viewpoint we discuss the best techniques for AF ablation.

Of the new catheter-based approaches, two have emerged as dominant strategies in current clinical practice: ostial pulmonary vein (PV) isolation and our approach, circumferential PV ablation (CPVA).1,2 PV isolation separates the dominant source of triggers that initiate AF,1 while CPVA eliminates both the triggers and the substrate that initiate and maintain AF.2 A recent randomized comparison found that our strategy using CPVA was more effective than segmental PV isolation in patients with paroxysmal AF, which suggests that the superiority of CPVA might depend on the amount of substrate modified.3 Although the efficacy and safety of the two ablation strategies have been established for patients with paroxysmal AF, PV isolation alone is not sufficient to treat permanent AF.1 Furthermore, the extremely encouraging results of CPVA, even in patients with permanent AF—who represent the majority of AF patients—suggest that our approach should be preferred in all patients undergoing AF ablation. Since demonstrating 5 years ago that CPVA is safe and does not require long procedural times, some electrophysiologic groups, including Sanders et al., the pioneering group from Bordeaux, have substantially changed their initial ablation strategy from focal or PV isolation to more-extensive lesions and modification of the atrial substrate.4 The Bordeaux group has shown that deployment of linear lesions is performed in at least 50% of patients with paroxysmal AF undergoing PV isolation, and the overall success rate without antiarrhythmic medication at 6 months is reported to be 91%. Therefore, it has become evident that more-extensive lesions, such as those initially performed by our group,2 remain the key to successful AF ablation;4,5 they isolate PV ectopy, which could initiate AF, reduce the potential of re-entry circuits, which can act as mother rotors, and modulate the local autonomic nervous system by destroying vagal nerve endings endocardially. Conversely, surgical compartmentalization of the atria was highly effective in restoring and maintaining sinus rhythm in patients with permanent AF; however, early attempts to replicate the surgical approach with ablation catheters by creating long, linear lesions in the left atrium were associated with high complication rates. Although they are safer, linear lesions limited to the right atrium showed low efficacy in preventing recurrences in permanent AF and have therefore been abandoned. The delivery of long, linear lesions in the left atrium and ensuring completeness of ablation lines can be effective but technically challenging, requiring a mean procedure time of 8 h.6 Our approach, which has been performed on more than 7,000 patients (59% with permanent AF, 45% with structural heart disease and 44% with enlarged atria) and does not necessarily require complete ablation lines, is a feasible and simple technique with acceptable risks. In general, complications were not serious and only one case of nonfatal atrioesophageal fistula occurred. Notably, postablation atrial tachycardia develops in less than 4% of patients. Most importantly, in patients with permanent AF the technique is associated with maintenance of sinus rhythm similar to that achieved with the surgical maze.

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Authors and Affiliations

  1. Department of Arrhythmology,

    Carlo Pappone & Vincenzo Santinelli

  2. Scientific Director of arrhythmology at San Raffaele University-Hospital, Milan, Italy

    Carlo Pappone & Vincenzo Santinelli

Authors
  1. Carlo Pappone
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  2. Vincenzo Santinelli
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Correspondence to Carlo Pappone.

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The authors declare no competing financial interests.

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Pappone, C., Santinelli, V. Atrial fibrillation ablation: a realistic alternative to pharmacologic therapy. Nat Rev Cardiol 2, 608–609 (2005). https://doi.org/10.1038/ncpcardio0373

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