Atrial Fibrillation Ablation: State of the Art

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Among several catheter-based strategies for curing atrial fibrillation (AF), 2 approaches have emerged as dominant strategies in current clinical practice: ostial segmental disconnection of all pulmonary veins (PVs) from the adjacent atrial tissue and circumferential PV ablation, first reported by our laboratory in Milan. The cure for AF by circumferential PV ablation has had a dramatic impact on morbidity, quality of life, and even mortality in patients with the most frequent cardiac arrhythmia. The last 10 years of AF ablation are characterized by a better understanding of AF mechanisms as well as by new and evolving concepts associated with innovation in technologies. We recently demonstrated, for the first time, the role of vagal denervation in enhancing long-term benefits from circumferential PV ablation. Unlike other strategies, our strategy was associated with high success rates in both paroxysmal and chronic AF. As a result, our initial approach did not substantially change over time, and now we have long-term results after >3 years of follow-up. Recently, we demonstrated the safety and feasibility of remote magnetic navigation of a soft magnetic-tip catheter within the left atrium, even at challenging sites for both mapping and ablation in patients with AF. Use of a robotic navigation system has begun a new era in interventional cardiac electrophysiology—without risk of major complications, such as cardiac tamponade or atrioesophageal fistula, even in less experienced laboratories.

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Current Atrial Fibrillation Ablation Strategies: Comparative Data

Among several catheter-based strategies for AF treatment, 2 have emerged as dominant strategies in current clinical practice: 1 is aimed at ostial segmental disconnection of all PVs from the adjacent atrial tissue, and the other is aimed at anatomic circumferential ablation outside the PV ostia with additional lines as first described by our group.1 Is either of the 2 ablation strategies superior to the other, since the 2 proposed strategies are based on different rationales, require different

Atrial Fibrillation Mechanisms

To assess whether 1 strategy is superior to the other, it is crucial to understand the mechanisms that underlie human AF since the 2 proposed strategies are based on different rationales. The mechanisms of AF are complex and not yet well defined (Figure 1).8, 10, 14, 15, 16 Improvements in catheter ablation techniques essentially depend on better understanding of the mechanisms of this arrhythmia. Chronic AF is a highly heterogeneous and complex disease, and there are different mechanisms in

Anatomic Considerations

PV anatomic variability may have potential implications in the choice of the ablation approach. In patients with such PV anatomic variations, the circumferential approach is more favorable. One such variation is the presence of a common ostium of the left PVs, occurring in ≤32% of patients undergoing PV isolation. Such common ostia typically are too large to allow a stable position of the circumferential mapping catheter. Another anatomic variation is the presence of a right middle-lobe PV,

Patient population and selection

Over the last 5 years, >6,000 patients with either paroxysmal or chronic AF, many of whom had associated structural heart disease, were referred to our department for circumferential PV ablation. In our series the presence of heart failure, coronary artery disease, and mechanical prosthetic valves did not affect the outcome.

Mapping and ablation procedure

Three catheters are usually used: (1) a standard bipolar or quadripolar catheter in the right ventricular apex to provide backup pacing, (2) a quadripolar catheter in the

Safety and Efficacy

Complications of circumferential LA ablation are reported in Table 1. Postablation LA flutter is relatively common but usually does not require a repeat procedure because it generally resolves spontaneously within 5 months after the index procedure. Atrioesophageal fistula is rare, but its occurrence is dramatic and devastating.5 Lower RF energy application is recommended when ablating on the LA posterior wall; at present, the line is made on the posterior wall near the roof of the left atrium,

Anatomic, Electrical, and Functional Remodeling After Pulmonary Vein Ablation

Restoration of SR after ablation (usually by 5-month follow-up) results in “reverse” electrical and mechanical atrial remodeling and improved atrial function. Enlarged atria may become smaller, and this is associated with both electrical and mechanical changes. Among patients with mitral regurgitation who undergo ablation, anatomic remodeling is more pronounced and, interestingly, is associated with reduced mitral regurgitation and improved left ventricular function compared with patients in

Remote magnetic catheter navigation system for mapping and ablation of AF—a new era in interventional electrophysiology

A novel and promising approach to transcatheter AF ablation is the robotic magnetic navigation system for accurate mapping and ablation. The initial experience with this system in our laboratory has shown that the remote control of a soft magnetic catheter in patients with either paroxysmal or chronic AF is safe and feasible. This navigation system is integrated with a newly developed electroanatomic CARTO RMT (Biosense Webster, Inc.) mapping system. A special magnetic 4-mm tip mapping and

Conclusion

The circumferential PV approach to ablation can be safely performed in most patients with either paroxysmal or chronic AF, with high success rates that are maintained over the long term. With practice and new technology development, the procedure can be accomplished more quickly and can be safely performed even in less experienced centers, thus improving patient tolerance and exposing the patient to less risk.

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