Improving ablation strategies for the treatment of atrial fibrillation

Abstract

Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. The contemporary management of AF is centered on symptomatic improvement, as well as reduction in the AF associated morbidity and mortality. For many highly symptomatic patients catheter ablation offers an efficacious means to maintaining sinus rhythm when antiarrhythmic drugs have been ineffective, are contraindicated or cannot be tolerated. Over the past 15 years, catheter ablation has moved from an ‘experimental therapy’ to the standard of care for the maintenance of sinus rhythm. Unfortunately, while the results of ablation are unequivocally superior to medical therapy, recognized limitations of the contemporary AF ablation procedures have spurred several developments designed to improve the efficacy of the index ablation procedure, while limiting adverse events. The purpose of this review is to discuss the procedural refinements, and technological innovations proposed to outcomes of patients undergoing a percutaneous catheter ablation procedure for AF.

Keywords::

• ablation
• atrial fibrillation
• cryoballoon
• laser balloon
• multi-electrode
• radiofrequency

Financial & competing interests disclosure

J Andrade and L Macle have received research support or honoraria from Medtronic. L Macle has received research support or honoraria from St. Jude, Boehringer Ingelheim, and Johnson & Johnson. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Atrial fibrillation (AF) is the most common sustained arrhythmia seen in clinical practice, affecting 1–2% of the overall population and accounting for with the direct costs of AF management accounting for approximately 1% of total healthcare expenditures.

• While antiarrhythmic drugs remain the ‘first-line’ therapy for the maintenance of sinus rhythm, these medications have only modest efficacy at maintaining sinus rhythm over the long term.

• For many highly symptomatic patients who cannot be pharmacologically controlled, catheter ablation offers an efficacious alternative to maintaining sinus rhythm when drugs have been ineffective or cannot be tolerated.

• Though the results of ablation are unequivocally superior to medical therapy, they are not perfect, leading to various technological and strategic modifications to the procedure.

• Novel ablation energies (cryothermal ablation, laser ablation) and novel ablation catheter designs (balloon-based and multi-electrode ablation) have shown promise, but as of yet have not necessarily improved outcomes over standard RF ablation.

• Contact force technology represents a major technological development, however, data from large scale randomized studies is needed in order to judge their effectiveness.

• Studies examining the role of substrate modification (linear ablation, complex fractionated atrial electrograms ablation and ablation of rotors) will hopefully better delineate the optimal ablation strategy and improve outcomes for those patients with persistent AF undergoing an ablation procedure.

Notes