Abstract
The procedure of catheter ablation for the treatment of drug resistant atrial fibrillation (AF) has evolved but still relies on lesion sets intended to isolate areas of focal firing, mainly the myocardial sleeves of the pulmonary veins (PVs), from the rest of the atria. However the success rates for this procedure have varied inversely with the type of AF. At best success rates have been 20 to 30% below that of other catheter ablation procedures for Wolff-Parkinson-White syndrome, atrioventricular junctional re-entrant tachycardia and atrial flutter. Basic and clinical evidence has emerged suggesting a critical role of the ganglionated plexi (GP) at the PV-atrial junctions in the initiation and maintenance of the focal form of AF. At present the highest success rates have been obtained with the combination of PV isolation and GP ablation both as catheter ablation or minimally invasive surgical procedures. Various lines of evidence from earlier and more recent reports provide that both neurally based and myocardially based forms of AF can separately dominate or coexist within the context of atrial remodeling. Future studies are focusing on non-pharmacological, non-ablative approaches for the prevention and treatment of AF in order to avoid the substantive complications of both these regimens.
Highlights
The examination of a patient with chest palpitations and an irregular and rapid pulse was more definitively diagnosed and designated as auricular fibrillation with the advent of the electrocardiogram at the beginning of the 20th century
Two schools of thought developed, each with its chief proponents, each based on accumulated experimental evidence, which were apparently contradictory to one another. Scherf and his associates [1, 2] promulgated the focal theory of atrial fibrillation (AF) by demonstrating that substances, such as aconitine [1] or acetylcholine applied to the atrial appendage or to the area of the sinus/AV node, [2] could induce a rapid auricular tachycardia or auricular fibrillation, respectively
Transmural lesions sets, similar to those produced surgically, were instituted using radiofrequency energy delivered to ISRN Cardiology the left and/or right atrial endocardium [5, 6]. This approach was an extension of what was found to be highly successful in cutting the reentrant circuits involved in Wolff-Parkinson-White (WPW) syndrome, atrioventricular junctional reentrant tachycardia (AVJRT), and atrial flutter (AFL)
Summary
The examination of a patient with chest palpitations and an irregular and rapid pulse was more definitively diagnosed and designated as auricular fibrillation with the advent of the electrocardiogram at the beginning of the 20th century. Initial studies by Moe [3] provided strong evidence for multiple wavelets (reentrant circuits) occupying the atria during AF induced by triggering atrial premature beats along with vagal nerve stimulation. More sophisticated mapping techniques employed by Allessie and coworkers [4], using the same experimental model, clearly demonstrated the existence of several reentrant circuits traversing the atria giving unambiguous support for Moe’s multiple wavelet hypothesis
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