Abstract
Catheter ablation is an important treatment modality for patients with atrial fibrillation (AF). Although the superiority of catheter ablation over antiarrhythmic drug therapy has been demonstrated in middle-aged patients with paroxysmal AF, the role the procedure in other patient subgroups—particularly those with long-standing persistent AF—has not been well defined. Furthermore, although AF ablation can be performed with reasonable efficacy and safety by experienced operators, long-term success rates for single procedures are suboptimal. Fortunately, extensive ongoing research will improve our understanding of the mechanisms of AF, and considerable funds are being invested in developing new ablation technologies to improve patient outcomes. These technologies include ablation catheters designed to electrically isolate the pulmonary veins with improved safety, efficacy, and speed, catheters designed to deliver radiofrequency energy with improved precision, robotic systems to address the technological demands of the procedure, improved imaging and electrical mapping systems, and MRI-guided ablation strategies. The tools, technologies, and techniques that will ultimately stand the test of time and become the standard approach to AF ablation in the future remain unclear. However, technological advances are sure to result in the necessary improvements in the safety and efficacy of AF ablation procedures.
Key Points
-
Catheter ablation is a commonly performed procedure for the treatment of atrial fibrillation (AF)
-
Electrical isolation of the pulmonary veins is the cornerstone of most AF ablation procedures
-
The use of an irrigated ablation catheter, in conjunction with an electroanatomic mapping system, is currently the most common approach to AF ablation
-
New technologies and tools are being developed to make catheter ablation of AF safer and more effective, and to decrease the time and technical skill required to perform the procedure
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$209.00 per year
only $17.42 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Fuster, V. et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J. Am. Coll. Cardiol. 48, 854–906 (2006).
Calkins, H. et al. HRS/EHRA/ECAS expert consensus statement on catheter ablation and surgical ablation of atrial fibrillation: recommendation for personal, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Europace 9, 335–379 (2007).
Calkins, H. et al. Treatment of atrial fibrillation with antiarrhythmic drugs or radio frequency ablation: two systematic literature reviews and meta-analyses. Circ. Arrhythmia Electrophysiol. doi:10.1161/CIRCEP.108.824789.
Wazni, O. M. et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. JAMA 293, 2634–2640 (2005).
Stabile, G. et al. Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multi-centre, randomized, controlled study (Catheter Ablation for the Cure of Atrial Fibrillation Study). Eur. Heart J. 27, 216–221 (2006).
Jaïs, P. et al. Catheter ablation versus antiarrhythmic drugs for atrial fibrillation: the A4 study. Circulation 1 18, 2498–2505 (2008).
Noeria, A., Kumar, A., Wylie Jr, J. V. & Josephson, M. E. Catheter ablation vs antiarrhythmic drug therapy for atrial fibrillation: a systematic review. Arch. Intern. Med. 168, 581–586 (2008).
Cappato, R. et al. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation 111, 1100–1105 (2005).
Spragg, D. D. et al. Complications of catheter ablation for atrial fibrillation: incidence and predictors. J. Cardiovasc. Electrophysiol. 19, 627–631 (2008).
Cappato, R. et al. Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. J. Am. Coll. Cardiol. 53, 1798–1803 (2009).
Nademanee, K. et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J. Am. Coll. Cardiol. 43, 2044–2053 (2004).
Nademanee, K. et al. Clinical outcomes of catheter substrate ablation for high-risk patients with atrial fibrillation. J. Am. Coll. Cardiol. 51, 843–849 (2008).
Oral, H. et al. A randomized assessment of the incremental role of ablation of complex fractionated atrial electrograms after antral pulmonary vein isolation for long-lasting persistent atrial fibrillation. J. Am. Coll. Cardiol. 53, 782–789 (2009).
Haïssaguerre, M. et al. Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subsequent arrhythmias. J. Cardiovasc. Electrophysiol. 16, 1138–1147 (2005).
Haïssaguerre, M. et al. Catheter ablation of long-lasting persistent atrial fibrillation: critical structures for termination. J. Cardiovasc. Electrophysiol. 16, 1125–1137 (2005).
Zado, E. et al. Long-term clinical efficacy and risk of catheter ablation for atrial fibrillation in the elderly. J. Cardiovasc. Electrophysiol. 19, 621–626 (2008).
Hsu, L. F. et al. Catheter ablation for atrial fibrillation in congestive heart failure. N. Engl. J. Med. 351, 2373–2383 (2004).
Khan, M. N. et al. for the PABA-CHF Investigators. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N. Engl. J. Med. 359, 1778–1785 (2008).
Van Belle, Y. et al. Pulmonary vein isolation using an occluding cryoballoon for circumferential ablation: feasibility, complications, and short-term outcome. Eur. Heart J. 28, 2231–2237 (2007).
Chun, K. R. et al. The 'single big cryoballoon' technique for acute pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a prospective observational single centre study. Eur. Heart J. 30, 699–709 (2009).
Neumann, T. et al. Circumferential pulmonary vein isolation with the cryoballoon technique: results from a prospective 3-center study. J. Am. Coll. Cardiol. 52, 273–278 (2008).
Moreira, W. et al. Long-term follow-up after cryothermic ostial pulmonary vein isolation in paroxysmal atrial fibrillation. J. Am. Coll. Cardiol. 51, 850–855 (2008).
Phillips, K. P. et al. Anatomic location of pulmonary vein electrical disconnection with balloon-cased catheter ablation. J. Cardiovasc. Electrophysiol. 19, 14–18 (2008).
Reddy, V. Y. et al. Balloon catheter ablation to treat paroxysmal atrial fibrillation: what is the level of pulmonary venous isolation? Heart Rhythm 5, 353–360 (2008).
Schmidt, B. et al. Pulmonary vein isolation by high-intensity focused ultrasound: first-in-man study with a steerable balloon catheter. Heart Rhythm 4, 575–584 (2007).
Nakagawa, H. et al. Initial experience using a forward direct, high-intensity focused ultrasound balloon catheter for pulmonary vein antrum isolation in patients with atrial fibrillation. J. Cardiovasc. Electrophysiol. 18, 136–144 (2007).
Borchert, B., Lawrenz, T., Hansky, B. & Stellbrink, C. Lethal atrioesophageal fistula after pulmonary vein isolation using high-intensity focused ultrasound (HIFU). Heart Rhythm 5, 145–148 (2008).
Boersma, L. V., Wijffels, M. C., Oral, H., Wever, E. F. & Morady, F. Pulmonary vein isolation by duty-cycled bipolar and unipolar radiofrequency energy with a multielectrode ablation catheter. Heart Rhythm 5, 1635–1642 (2008).
Fredersdorf, S. et al. Safe and rapid isolation of pulmonary veins using a novel circular ablation catheter and duty-cycled RF generator. J. Cardiovasc. Electrophysiol. 20, 1097–1101 (2009).
ClinicalTrials.gov. The Tailored Treatment of Permanent Atrial Fibrillation (TTOP AF) Trial (NCT00514735) [online], (2009).
Meissner, A. et al. First experiences for pulmonary vein isolation with the high-density mesh ablator (HDMA): a novel mesh electrode catheter for both mapping and radiofrequency delivery in a single unit. J. Cardiovasc. Electrophysiol. 20, 359–366 (2009).
De Filippo, P., He, D. S., Brambilla, R., Gavazzi, A. & Cantú, F. Clinical experience with a single catheter for mapping and ablation of pulmonary vein ostium. J. Cardiovasc. Electrophysiol. 20, 367–373 (2009).
Mansour, M. et al. Initial experience with the Mesh catheter for pulmonary vein isolation in patients with paroxysmal atrial fibrillation. Heart Rhythm 5, 1510–1516 (2008).
Steinwender, C., Honig, S., Leisch, F. & Hofmann, R. Acute results of pulmonary vein isolation in patients with paroxysmal atrial fibrillation using a single mesh catheter. J. Cardiovasc. Electrophysiol. 20, 147–152 (2009).
Estner, H. L. et al. Electrogram-guided substrate ablation with or without pulmonary vein isolation in patients with persistent atrial fibrillation. Europace 10, 1281–1287 (2008).
Porter, M. et al. Prospective study of atrial fibrillation termination during ablation guided by automated detection of fractionated electrograms. J. Cardiovasc. Electrophysiol. 19, 613–620 (2008).
Calò, L. et al. Diagnostic accuracy of a new software for complex fractionated electrograms identification in patients with persistent and permanent atrial fibrillation. J. Cardiovasc. Electrophysiol. 19, 1024–1030 (2008).
Wu, J. et al. Automatic 3D mapping of complex fractionated atrial electrograms (CFAE) in patients with paroxysmal and persistent atrial fibrillation. J. Cardiovasc. Electrophysiol. 19, 897–903 (2008).
Scherr, D. et al. Automated detection and characterization of complex fractionated atrial electrograms in human left atrium during atrial fibrillation. Heart Rhythm 4, 1013–1020 (2007).
Pappone, C. et al. Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation. Circulation 109, 327–334 (2004).
Scherlag, B. J., Yamanashi, W., Patel, U., Lazzara, R. & Jackman, W. M. Autonomically induced conversion of pulmonary vein focal firing into atrial fibrillation, J. Am. Coll. Cardiol. 45, 1878–1886 (2005).
Katritsis, D., Giazitzoglou, E., Sougiannis, D., Voridis, E. & Po, S. S. Complex fractionated atrial electrograms at anatomic sites of ganglionic plexi in atrial fibrillation. Europace 11, 308–315 (2009).
Hou, Y. et al. Ganglionic plexi modulate extrinsic cardiac autonomic nerve input: effects on sinus rate, atrioventricular conduction, refractoriness, and inducibility of atrial fibrillation. J. Am. Coll. Cardiol. 50, 61–68 (2007).
Danik, S. et al. Evaluation of catheter ablation of periatrial ganglionic plexi in patients with atrial fibrillation. Am. J. Cardiol. 102, 578–583 (2008).
Lemery, R., Birnie, D., Tang, A. S., Green, M. & Gollob, M. Feasibility study of endocardial mapping of ganglionated plexuses during catheter ablation of atrial fibrillation. Heart Rhythm 3, 387–396 (2006).
Katritsis, D. et al. Anatomic approach for ganglionic plexi ablation in patients with paroxysmal atrial fibrillation. Am. J. Cardiol. 102, 330–334 (2008).
Kim, A. M. et al. Impact of remote magnetic catheter navigation on ablation fluoroscopy and procedure time. Pacing Clin. Electrophysiol. 31, 1399–1404 (2008).
Pappone, C. et al. Robotic magnetic navigation for atrial fibrillation ablation. J. Am. Coll. Cardiol. 47, 1390–1400 (2006).
Di Biase, L. et al. Relationship between catheter forces, lesions characteristics, “popping,” and char formation: experience with robotic navigation system. J. Cardiovasc. Electrophysiol. 20, 436–440 (2009).
Katsiyiannis, W. T. et al. Feasibility and safety of remote-controlled magnetic navigation for ablation of atrial fibrillation. Am. J. Cardiol. 10 2, 1674–1676 (2008).
Schmidt, B. et al. Remote robotic navigation and electroanatomical mapping for ablation of atrial fibrillation: considerations for navigation and impact on procedural outcome. Circ. Arrhythmia Electrophysiol. 2, 120–128 (2009).
Saliba, W. et al. Atrial fibrillation ablation using a robotic catheter remote control system: initial human experience and long-term follow-up results. J. Am. Coll. Cardiol. 51, 2407–2411 (2008).
McGann, C. J. et al. New magnetic resonance imaging-based method for defining the extent of left atrial wall injury after the ablation of atrial fibrillation. J. Am. Coll. Cardiol. 52, 1263–1271 (2008).
Peters, D. C. et al. Recurrence of atrial fibrillation correlates with the extent of post-procedural late gadolinium enhancement: a pilot study. JACC Cardiovac Imaging 2, 308–316 (2009).
Nazarian, S. et al. Feasibility of real-time magnetic resonance imaging for catheter guidance in electrophysiology studies. Circulation 118, 223–229 (2008).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
H. Calkins has acted as a consultant for Ablation Frontiers, Biosense Webster, Medtronic, and Sanofi-Aventis and has received research support from Biosense Webster. J. Dewire declares no competing interests.
Rights and permissions
About this article
Cite this article
Dewire, J., Calkins, H. State-of-the-art and emerging technologies for atrial fibrillation ablation. Nat Rev Cardiol 7, 129–138 (2010). https://doi.org/10.1038/nrcardio.2009.232
Issue Date:
DOI: https://doi.org/10.1038/nrcardio.2009.232
This article is cited by
-
Prevention of cerebral thromboembolism by oral anticoagulation with dabigatran after pulmonary vein isolation for atrial fibrillation: the ODIn-AF trial
Clinical Research in Cardiology (2023)
-
Catheter-integrated soft multilayer electronic arrays for multiplexed sensing and actuation during cardiac surgery
Nature Biomedical Engineering (2020)
-
A review: flexible, stretchable multifunctional sensors and actuators for heart arrhythmia therapy
Micro and Nano Systems Letters (2017)
-
Rationale and design of the ODIn-AF Trial: randomized evaluation of the prevention of silent cerebral thromboembolism by oral anticoagulation with dabigatran after pulmonary vein isolation for atrial fibrillation
Clinical Research in Cardiology (2016)
-
Flexible Sensory Platform Based on Oxide-based Neuromorphic Transistors
Scientific Reports (2015)