Skip to main content
Log in

Targets and endpoints in ablation therapy for atrial fibrillation in the light of pathophysiological mechanisms

  • Review
  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Atrial fibrillation (AF), an important public health problem is a complex and multifactorial arrhythmia. Non-pharmacological treatment for symptomatic patients is of increasing importance. The different catheter ablation techniques in AF treatment developed during recent years, all based on different pathophysiological insights, are discussed. The non-standardized use of different follow-up methods after ablation make interpretation and comparison of results difficult.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. McMichael J. History of atrial fibrillation 1628–1819 Harvey–-de Senac–-Laennec. Br. Heart J. 1982;48:193–197.

    CAS  PubMed  Google Scholar 

  2. Lip GY, Beevers DG. ABC of atrial fibrillation. History, epidemiology, and importance of atrial fibrillation. BMJ. 1995;311:1361–1363.

    CAS  PubMed  Google Scholar 

  3. Flegel KM. From delirium cordis to atrial fibrillation: historical development of a disease concept. Ann Intern Med. 1995;122:867–873.

    CAS  PubMed  Google Scholar 

  4. Gallagher MM, Camm AJ. Classification of atrial fibrillation. Pacing Clin Electrophysiol. 1997;20:1603–1605.

    CAS  PubMed  Google Scholar 

  5. Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation–-Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. In: Lancet; 2000;1789–1794.

  6. Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG, Crijns HJ. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. In: N Engl J Med; 2002:1834–1840.

  7. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD. A comparison of rate control and rhythm control in patients with atrial fibrillation. In: N Engl J Med; 2002:1825–1833.

  8. Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med. 1982;306:1018–1022.

    Article  CAS  PubMed  Google Scholar 

  9. Reardon M, Camm AJ. Atrial fibrillation in the elderly. Clin Cardiol. 1996;19:765–775.

    Article  CAS  PubMed  Google Scholar 

  10. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, Singer DE. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001;285:2370–2375.

    Article  CAS  PubMed  Google Scholar 

  11. Cairns JA, Connolly SJ. Nonrheumatic atrial fibrillation. Risk of stroke and role of antithrombotic therapy. Circulation. 1991;84:469–481.

    CAS  PubMed  Google Scholar 

  12. Onundarson PT, Thorgeirsson G, Jonmundsson E, Sigfusson N, Hardarson T. Chronic atrial fibrillation–epidemiologic features and 14 year follow-up: a case control study. Eur Heart J. 1987;8:521–527.

    CAS  PubMed  Google Scholar 

  13. Peters RW, Gold MR. The influence of gender on arrhythmias. Cardiol Rev. 2004;12:97–105.

    Article  PubMed  Google Scholar 

  14. Friberg J, Scharling H, Gadsboll N, Jensen GB. Sex-specific increase in the prevalence of atrial fibrillation (The Copenhagen City Heart Study). Am J Cardiol. 2003;92:1419–1423.

    Article  PubMed  Google Scholar 

  15. Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med. 1995;155:469–473.

    Article  CAS  PubMed  Google Scholar 

  16. Moe GK. On the multiple wavelet hypothesis of atrial fibrillation. Arch Int Pharmacodyn. 1962;140:183–188.

    Google Scholar 

  17. Allessie M, Lammers W, Bonke FJ. Experimental evaluation of Moe’s multiple wavelet hypothesis of atrial fibrillation. In: Zipes D, Jalife J, eds. Cardiac electrophysiology and arrhythmias. Orlando, Grune and Stratton 1985:265–275.

  18. Wijffels MC, Kirchhof CJ, Dorland R, Allessie MA. Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation. 1995;92:1954–1968.

    CAS  PubMed  Google Scholar 

  19. Ausma J, Wijffels M, van Eys G, Koide M, Ramaekers F, Allessie M, Borgers M. Dedifferentiation of atrial cardiomyocytes as a result of chronic atrial fibrillation. Am J Pathol. 1997;151:985–997.

    CAS  PubMed  Google Scholar 

  20. Manning WJ, Silverman DI, Katz SE, Riley MF, Come PC, Doherty RM, Munson JT, Douglas PS. Impaired left atrial mechanical function after cardioversion: relation to the duration of atrial fibrillation. J Am Coll Cardiol. 1994;23:1535–1540.

    Article  CAS  PubMed  Google Scholar 

  21. Cox JL, Schuessler RB, D’Agostino HJ, Jr., Stone CM, Chang BC, Cain ME, Corr PB, Boineau JP. The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg. 1991;101:569–583.

    CAS  PubMed  Google Scholar 

  22. Ernst S, Schluter M, Ouyang F, Khanedani A, Cappato R, Hebe J, Volkmer M, Antz M, Kuck KH. Modification of the substrate for maintenance of idiopathic human atrial fibrillation: efficacy of radiofrequency ablation using nonfluoroscopic catheter guidance. Circulation. 1999;100:2085–2092.

    CAS  PubMed  Google Scholar 

  23. Konings KT, Kirchhof CJ, Smeets JR, Wellens HJ, Penn OC, Allessie MA. High-density mapping of electrically induced atrial fibrillation in humans. Circulation. 1994;89:1665–1680.

    CAS  PubMed  Google Scholar 

  24. Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, Khunnawat C, Ngarmukos T. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol. 2004;43:2044–2053.

    Article  PubMed  Google Scholar 

  25. Pachon MJ, Pachon ME, Lobo TJ, Pachon MZ, Vargas RN, Pachon DQ, Lopez MF, Jatene AD. A new treatment for atrial fibrillation based on spectral analysis to guide the catheter RF-ablation. Europace. 2004;6:590–601.

    Article  PubMed  Google Scholar 

  26. Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, Le Mouroux A, Le Metayer P, Clementy J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659–666.

    Article  CAS  PubMed  Google Scholar 

  27. Macle L, Jais P, Scavee C, Weerasooriya R, Shah DC, Hocini M, Choi KJ, Raybaud F, Clementy J, Haissaguerre M. Electrophysiologically guided pulmonary vein isolation during sustained atrial fibrillation. J Cardiovasc Electrophysiol. 2003;14:255–260.

    Article  PubMed  Google Scholar 

  28. Mandapati R, Skanes A, Chen J, Berenfeld O, Jalife J. Stable microreentrant sources as a mechanism of atrial fibrillation in the isolated sheep heart. In: Circulation; 2000:194–199.

  29. Waldo AL. Mechanisms of atrial fibrillation. J Cardiovasc Electrophysiol. 2003;14:S267–274.

    Article  PubMed  Google Scholar 

  30. Ramanna H, De Bakker JM, Elvan A, Hauer RN. On the atrial response to focal discharges in man. J Cardiovasc Electrophysiol. 2004;15:629–636.

    Article  PubMed  Google Scholar 

  31. Jais P, Hocini M, Macle L, Choi KJ, Deisenhofer I, Weerasooriya R, Shah DC, Garrigue S, Raybaud F, Scavee C, Le Metayer P, Clementy J, Haissaguerre M. Distinctive electrophysiological properties of pulmonary veins in patients with atrial fibrillation. In: Circulation; 2002:2479–2485.

  32. Nakagawa H, Jackman WM, Scherlag BJ, Lazzara R. Pulmonary vein isolation during atrial fibrillation: insight into the mechanism of pulmonary vein firing. J Cardiovasc Electrophysiol. 2003;14:261–262.

    Article  PubMed  Google Scholar 

  33. Kalifa J, Jalife J, Zaitsev AV, Bagwe S, Warren M, Moreno J, Berenfeld O, Nattel S. Intra-atrial pressure increases rate and organization of waves emanating from the superior pulmonary veins during atrial fibrillation. In: Circulation; 2003:668–671.

  34. Tse HF, Reek S, Timmermans C, Lee KL, Geller JC, Rodriguez LM, Ghaye B, Ayers GM, Crijns HJ, Klein HU, Lau CP. Pulmonary vein isolation using transvenous catheter cryoablation for treatment of atrial fibrillation without risk of pulmonary vein stenosis. In: J Am Coll Cardiol; 2003:752–758.

  35. Marrouche NF, Martin DO, Wazni O, Gillinov AM, Klein A, Bhargava M, Saad E, Bash D, Yamada H, Jaber W, Schweikert R, Tchou P, Abdul-Karim A, Saliba W, Natale A. Phased-array intracardiac echocardiography monitoring during pulmonary vein isolation in patients with atrial fibrillation: impact on outcome and complications. Circulation. 2003;107:2710–2716.

    Article  PubMed  Google Scholar 

  36. Schauerte P, Scherlag BJ, Patterson E, Scherlag MA, Matsudaria K, Nakagawa H, Lazzara R, Jackman WM. Focal atrial fibrillation: experimental evidence for a pathophysiologic role of the autonomic nervous system. J Cardiovasc Electrophysiol. 2001;12:592–599.

    Article  CAS  PubMed  Google Scholar 

  37. Coumel P, Friocourt P, Mugica J, Attuel P, Leclercq JF. Long-term prevention of vagal atrial arrhythmias by atrial pacing at 90/minute: experience with 6 cases. Pacing Clin Electrophysiol. 1983;6:552–560.

    CAS  PubMed  Google Scholar 

  38. Pappone C, Santinelli V, Manguso F, Vicedomini G, Gugliotta F, Augello G, Mazzone P, Tortoriello V, Landoni G, Zangrillo A, Lang C, Tomita T, Mesas C, Mastella E, Alfieri O. Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation. Circulation. 2004;109:327–334.

    Article  PubMed  Google Scholar 

  39. Pappone C, Rosanio S, Oreto G, Tocchi M, Gugliotta F, Vicedomini G, Salvati A, Dicandia C, Mazzone P, Santinelli V, Gulletta S, Chierchia S. Circumferential radiofrequency ablation of pulmonary vein ostia: A new anatomic approach for curing atrial fibrillation. Circulation. 2000;102:2619–2628.

    CAS  PubMed  Google Scholar 

  40. Stabile G, Turco P, La Rocca V, Nocerino P, Stabile E, De Simone A. Is pulmonary vein isolation necessary for curing atrial fibrillation? Circulation. 2003;108:657–660.

    Article  PubMed  Google Scholar 

  41. Ouyang F, Antz M, Ernst S, Hachiya H, Mavrakis H, Deger FT, Schaumann A, Chun J, Falk P, Hennig D, Liu X, Bansch D, Kuck KH. Recovered pulmonary vein conduction as a dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of the pulmonary veins: lessons from double Lasso technique. In: Circulation; 2005:127–135.

  42. Oral H, Chugh A, Lemola K, Cheung P, Hall B, Good E, Han J, Tamirisa K, Bogun F, Pelosi F, Jr., Morady F. Noninducibility of atrial fibrillation as an end point of left atrial circumferential ablation for paroxysmal atrial fibrillation: a randomized study. Circulation. 2004;110:2797–2801.

    Article  PubMed  Google Scholar 

  43. Hsu LF, Jais P, Sanders P, Garrigue S, Hocini M, Sacher F, Takahashi Y, Rotter M, Pasquie JL, Scavee C, Bordachar P, Clementy J, Haissaguerre M. Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med. 2004;351:2373–2383.

    Article  CAS  PubMed  Google Scholar 

  44. Senatore G, Stabile G, Bertaglia E, Donnici G, De Simone A, Zoppo F, Turco P, Pascotto P, Fazzari M. Role of transtelephonic electrocardiographic monitoring in detecting short-term arrhythmia recurrences after radiofrequency ablation in patients with atrial fibrillation. J Am Coll Cardiol. 2005;45:873–876.

    Article  PubMed  Google Scholar 

  45. Hindricks G, Piorkowski C, Tanner H, Kobza R, Gerds-Li JH, Carbucicchio C, Kottkamp H. Perception of atrial fibrillation before and after radiofrequency catheter ablation: relevance of asymptomatic arrhythmia recurrence. Circulation. 2005;112:307–313.

    Article  PubMed  Google Scholar 

  46. Israel CW, Gronefeld G, Ehrlich JR, Li YG, Hohnloser SH. Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: implications for optimal patient care. In: J Am Coll Cardiol; 2004:47–52.

  47. Berkowitsch A, Neumann T, Kurzidim K, Reiner C, Kuniss M, Siemon G, Sperzel J, Pitschner HF. Comparison of generic health survey SF-36 and arrhythmia related symptom severity check list in relation to post-therapy AF recurrence. In: Europace; 2003:351–355.

  48. Pappone C, Rosanio S, Augello G, Gallus G, Vicedomini G, Mazzone P, Gulletta S, Gugliotta F, Pappone A, Santinelli V, Tortoriello V, Sala S, Zangrillo A, Crescenzi G, Benussi S, Alfieri O. Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study. In: J Am Coll Cardiol; 2003:185–197.

  49. Purerfellner H, Aichinger J, Martinek M, Nesser HJ, Ziegler P, Koehler J, Warman E, Hettrick D. Quantification of atrial tachyarrhythmia burden with an implantable pacemaker before and after pulmonary vein isolation. In: Pacing Clin Electrophysiol; 2004:1277–1283.

  50. Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. In: Circulation; 2005:1100–1105.

  51. Hocini M, Sanders P, Jais P, Hsu LF, Takahashi Y, Rotter M, Clementy J, Haissaguerre M. Techniques for curative treatment of atrial fibrillation. J Cardiovasc Electrophysiol. 2004;15:1467–1471.

    Article  PubMed  Google Scholar 

  52. Verma A, Marrouche NF, Natale A. Pulmonary vein antrum isolation: intracardiac echocardiography-guided technique. J Cardiovasc Electrophysiol. 2004;15:1335–1340.

    Article  PubMed  Google Scholar 

  53. Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E, Veerareddy S, Pelosi F, Jr., Morady F. Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. Circulation. 2003;108:2355–2360.

    Article  PubMed  Google Scholar 

  54. Allessie MA, Boyden PA, Camm AJ, Kleber AG, Lab MJ, Legato MJ, Rosen MR, Schwartz PJ, Spooner PM, Van Wagoner DR, Waldo AL. Pathophysiology and prevention of atrial fibrillation. Circulation. 2001;103:769–777.

    CAS  PubMed  Google Scholar 

  55. Schwartzman D, Bazaz R, Nosbisch J. Catheter ablation to suppress atrial fibrillation: evolution of technique at a single center. J Interv Card Electrophysiol. 2003;9:295–300.

    Article  PubMed  Google Scholar 

  56. Adragao P, Cavaco D, Aguiar C, Palos J, Morgado F, Ribeiras R, Abecasis M, Neves J, Bonhorst D, Seabra-Gomes R. Ablation of pulmonary vein foci for the treatment of atrial fibrillation; percutaneous electroanatomical guided approach. Europace. 2002;4:391–399.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Marcoen F. Scholten.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Scholten, M.F., Thornton, A.S., Mekel, J.M. et al. Targets and endpoints in ablation therapy for atrial fibrillation in the light of pathophysiological mechanisms . J Interv Card Electrophysiol 15, 27–33 (2006). https://doi.org/10.1007/s10840-006-6334-7

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-006-6334-7

Keywords

Navigation