Abstract
The electrophysiology of atrial fibrillation (AF) has always been a deep mystery in understanding this complex arrhythmia. The pathophysiological mechanisms of AF are complex and often remain unclear despite extensive research. Therefore, the implementation of basic science knowledge to clinical practice is challenging. After more than 20 years, pulmonary vein isolation (PVI) remains the cornerstone ablation strategy for maintaining the sinus rhythm (SR). However, there is no doubt that, in many cases, especially in persistent and long-standing persistent AF, PVI is not enough, and eventually, the restoration of SR occurs after additional intervention in the rest of the atrial myocardium. Substrate mapping is a modern challenge as it can reveal focal sources or rotational activities that may be responsible for maintaining AF. Whether these areas are actually the cause of the AF maintenance is unknown. If this really happens, then the targeted ablation may be the solution; otherwise, more rough techniques such as atrial compartmentalization may prove to be more effective. In this article, we attempt a broad review of the known pathophysiological mechanisms of AF, and we present the recent efforts of advanced technology initially to reveal the electrical impulse during AF and then to intervene effectively with ablation.
Highlights
In isolated dog hearts, using a Langendorff preparation, it was shown with simultaneous recording from 192 points in the atrial myocardium that the atrial fibrillation (AF) could be maintained by 3–6 wavelets rotating simultaneously
complex fractionated atrial electrograms (CFAEs) can be detected in 75% of areas with AF drivers, only 25% of CFAEs correspond to areas with drivers. is means that most CFAEs are noncritical areas for maintaining AF
In an era of rapid developments and changes in the field of AF ablation, it seems that in the coming years the wide PV isolation will remain the cornerstone as ablation strategy
Summary
Maintained during AF over an unexpectedly long period of time. e time of a complete rotation, which by definition represents the cycle length, was extremely short, and the frequency of depolarization was extremely high, leading to the reasonable assumption that the cause of the high frequency in the left atrium is the presence of rotors and spiral waves [31]. Focal impulse and rotor modulation (FIRM) is an innovating technique for simultaneous AF mapping developed a few years ago. It utilizes a 64-pole basket catheter of 8 splines containing 8 electrodes each that expands to come into contact with the wall of the left or right atrium, while simultaneously mapping the electrical activity during AF. Is technique, known as FIRM ablation, had very good results in the CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) clinical study [33] (Figure 9). AF mapping was attempted with the development of another technology with completely different conception which uses noninvasive body surface mapping By this technology, the electrical activity is recorded by 252 electrodes in the patient’s torso, and after computer processing
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