Abstract
In spite of technological progress and the improving skills of operators, atrial fibrillation (AF) ablation results appear to date to be at a plateau. In any case, the superiority of ablation over pharmacological therapy in terms of effectiveness, reduction of hospitalizations, and improvement has been well demonstrated in recent randomized trials. Triggers, substrate, and modulating factors (elements of Coumel's triangle) play different roles in paroxysmal and persistent AF, so induction and perpetuation mechanisms of arrhythmia may be different in each patient. Although effective ablative strategies are available for the treatment of paroxysmal AF triggers and persistent AF substrates, an adequate clinical evaluation of the patient is crucial in order to increase the chances of success. Recognizing triggers allows not only performing an effective ablation but also to avoid unnecessary lesions and at the same time reducing the risk of complications. AF beginning and triggers could be recorded by 12-lead ECG, continuous Holter monitoring, or implantable devices. In case of an unsuccessful noninvasive evaluation, nonpulmonary vein triggers should be investigated with an electrophysiological study. Persistent AF needs more effort to perform an accurate substrate characterization. Among the many methods proposed, recently the use of high-density mapping and multipolar catheters seems of particular benefit in order to clarify the arrhythmia mechanisms. Surgical and hybrid techniques allow to treat regions such as the posterior wall or Bachmann's bundle, which is fundamental for an ablative strategy that goes beyond just pulmonary vein isolation. Too often, patients are referred to electrophysiology laboratories without adequate preprocedural screening and planning in order to submit them to a standard “ready-made” procedure. The accurate search for triggers in paroxysmal AF and the correct recognition of the link between a possible underlying heart disease and the substrate in persistent AF could allow us to tailor the interventional approach in order to overcome the current plateau, increasing ablative procedure success and minimizing complications.
Highlights
Atrial fibrillation (AF) is the most common sustained arrhythmia, affecting approximately 3% of the adult population and nearly 6% of those over the age of 65 [1]
In the 1960s, Coumel et al described the mechanism of arrhythmias on the basis of the interaction of 3 elements: triggers, arrhythmogenic substrate, and modulating factors, which formed the socalled “Coumel’s triangle” [4, 5]. ese three elements play a different role in the pathogenesis of arrhythmias, and understanding the main mechanisms of each arrhythmia can help the physician select the best individual therapeutic approach [6]
Paroxysmal AF is defined as lasting
Summary
Atrial fibrillation (AF) is the most common sustained arrhythmia, affecting approximately 3% of the adult population and nearly 6% of those over the age of 65 [1]. The correlation between AF temporal classification and pathophysiology is poor, even if more frequently the paroxysmal form is trigger-related and the persistent one is mainly considered to be substrate-based. Even extracardiac factors such as the autonomic nervous system (modulating factor) can play a role in the triggering of vagal atrial fibrillation. It is possible to enact the ablative treatment of triggers in paroxysmal AF and that of the substrate in persistent AF, we should consider the clinical features of each patient in order to improve the interventional procedure outcome. By tailoring the ablative strategy in the single clinical setting, it may be possible to overcome the plateau achieved in terms of the success of AF ablation and to significantly increase the benefits/risks ratio
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