Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and represents a heterogeneous disorder with a complex pathological basis. While significant technological advances have taken place over the last decade in the field of catheter ablation of AF, response to ablation varies and long-term success rates in those with persistent AF remain modest. Mechanistic studies have highlighted potentially different sustaining factors for AF in the persistent AF population with substrate-driven focal and re-entrant sources in the body of the atria identified on invasive and non-invasive mapping studies. Translation to clinical practice, however, remains challenging and the application of such mapping techniques to clinical ablation has yet to demonstrate a significant benefit beyond pulmonary vein isolation (PVI) alone in the persistent AF cohort. Recent advances in catheter and ablation technology have centered on improving the durability of ablation lesions at index procedure and although encouraging results have been demonstrated with early studies, large-scale trials are awaited. Further meaningful improvement in clinical outcomes in the persistent AF population requires ongoing advancement in the understanding of AF mechanisms, coupled with continuing progress in catheter technology capable of delivering durable transmural lesions.
Highlights
In this review we provide an overview of the major ablation strategies utilized in the last two decades, we discuss developments in Atrial fibrillation (AF) mapping and its application to clinical ablation and we highlight contemporary advances in ablation technology demonstrating promise for the creation of durable lesion sets in the persistent
Progressive atrial remodeling beyond the pulmonary veins results in substrate-driven AF that is likely to be mechanistically different from that seen in paroxysmal disease, with further significant variation in the degree of remodeling within the persistent AF cohort itself
Despite the wealth of published data on adjunctive substrate-based ablation for persistent AF, no technique has demonstrated a consistent benefit over pulmonary vein isolation (PVI) alone, and latest guidelines underscore the central role of PVI in all patient populations
Summary
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Paroxysmal AF describes episodes terminating spontaneously or with intervention within seven days. In contrast to paroxysmal AF patients, in whom one-year success rates are reported as high as 90% with current workflows [3], outcomes are significantly more modest in persistent AF, with many patients requiring multiple procedures to maintain sinus rhythm. In these patients, progressive structural and electrical remodeling creates a substrate for the initiation and maintenance of AF in the body of the left atrium.
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