Looking to the Future in Managing Atrial Fibrillation

Login or register to view PDF.
Citation
US Cardiology, 2006;3(2):100-2

Pages

Atrial fibrillation (AF) is a common and recurrent arrhythmia resulting in significant morbidity and mortality. Our approach to the patient with AF has changed dramatically over the past decade. We have gone from palliating patients with rate controlling medications or administering antiarrhythmic medications with potential systemic side effects and proarrhythmia, to now curing many of them with a catheter-based ablative approach. In the next 10 years, looking to the future of AF therapy, even more dramatic progress in this field is predicted. This advancement will come with improvements to the catheter-based ablative approaches; establishment of an efficacious stand-alone surgical approach; emergence of suitable atrial antiarrhythmic medications; institution of superior methods to avoid thromboembolic events; and novel pharmacologic and genetic methods to prevent AF.

A catheter-based ablative approach was pioneered by Haissaguerre and colleagues when they discovered pulmonary vein (PV) potentials and their role in the initiation of AF. Later, JalifeÔÇÖs group reported on the importance of the posterior left atrium in the maintenance of this arrhythmia by microreentrant circuits or 'rotorsÔÇÖ exhibiting high-frequency activity from which spiral wavefronts of activation invade the left atrial tissue in an animal model of AF. Currently, the catheter-based ablative approaches to AF include:

  • segmental ostial ablation of the PV guided by a multipolar circumferential mapping catheter and fluoroscopy with an end-point of PV isolation described by Haissaguerre et al.;
  • a circumferential extra-ostial left atrial ablation with an end-point of ablation of left atrial signals within the circumferential areas around the right and left pulmonary veins described by Pappone et al.; and
  • more recently, an approach that targets complex fractionated electrograms recorded from both the right and left atria described by Nadamanee.

There are a variety of variants to these approaches pioneered by a number of investigators worldwide. These include ablation of the left atrium guided by intracardiac echocardiography (ICE) and antral isolation guided by multiple lasso catheters.

Improvements to the strategy, design, and technique of these original approaches have been made and continue to be spawned in order to improve efficacy. For instance, the addition of ablation in the coronary sinus, along the mitral annulus, the intra-atrial septum, and along the roof of the left atrium have all been incorporated into the ablative approach, especially in patients with persistent forms of AF, to improve effectiveness of the procedure.

Pages

References
  1. Fuster V, Ryden LE, Cannom DS et al., ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation.A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) , J Am Coll Cardiol (2006);48: pp. 854-906.
    Crossref
  2. Roy D,Talajic M, Dorian P et al., Amiodarone to prevent recurrence of atrial fibrillation: Canadian Trial of Atrial Fibrillation Investigators , N Engl J Med (2000);342:913-920.
    Crossref | PubMed
  3. Maintenance of sinus rhythm in patients with atrial fibrillation: an AFFIRM substudy of the first antiarrhythmic drug , J Am Coll Cardiol (2003);42: pp. 20-29.
    Crossref | PubMed
  4. Chun SH, Sager PT, Stevenson WG et al., Long-term efficacy of amiodarone for the maintenance of normal sinus rhythm in patients with refractory atrial fibrillation or flutter , Am J Cardiol (1995);76: pp. 47-50.
    Crossref | PubMed
  5. Haissaguerre M, Jais P, Shah DC et al., Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins , N Engl J Med (1998);339: p. 659.
    Crossref | PubMed
  6. Mandapati R, Skanes AC, Chen J, Berenfeld O, Jalife J, Stable minroreentrant sources as a mechanism of atrial fibrillation in the isolated sheep heart , Circulation (2000);101: pp. 194-199.
    Crossref | PubMed
  7. Haissaguerre M, Shah D, Jais P et al., Electrophysiological breakthroughs from the left atrium to the pulmonary veins , Circulation (2000);102: pp. 2463-2465.
    Crossref | PubMed
  8. Pappone C, Rosanio S, Oreto G et al., Circumferential radiofrequency ablation of pulmonary veins ostia: a new anatomic approach for curing atrial fibrillation , Circulation (2000);102: pp. 2619-2628.
    Crossref | PubMed
  9. Nademanee K, McKenzie J, Kosar E et al., A new approach for catheter ablation of atrial fibrillation: mapping of electrophysiologic substrate , J Am Coll Cardiol (2004);43: pp. 2044-2053.
    Crossref | PubMed
  10. Haissaguerre M, Hocini M, Sanders P et al., Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subseqhent arrhythmias , J Cardiovasc Electrophysiol (2005);16: pp. 1138-1147.
    Crossref | PubMed
  11. Malchano ZJ, Neuzil P, Cury RC et al., Integration of cardiac CT/MR imaging with three-dimensional electroanatomical mapping to guide catheter manipulation in the left atrium: implications for catheter ablation of atrial fibrillation , J Cardiovasc Electrophysiol (2006);17(11): p.1221
    Crossref | PubMed
  12. Gage AA, Baust J, Mechanisms of tissue injury , Cryobiology (1998);37: p. 171.
    Crossref | PubMed
  13. Oral H, Pappone C, Chigh A, Circumferential Pulmonary-Vein Ablation for Chronic Atrial Fibrillation , N Engl J Med (2006);354: pp. 934-941.
    Crossref | PubMed
  14. Cox JL, Schuessler RB, D'Agostino HJ Jr. et al., The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure , J Thorac Cardiovasc Surg (1991);101(4): pp. 569-583.
    PubMed
  15. Persson F, Carlsson L, Duker G et al., Blocking characteristics of hERG, hNav1.5 and hKvLQT1/hminK after administration of the novel antiarrhythmic compound AZD7009 , J Cardiovasc Electrophysiol (2005);16: pp. 329-341.
    Crossref | PubMed
  16. Blaauw Y, Goegelein H, Duytschaever M et al., Synergistic class III action of blockade of IKur/Ito (AVE0118) and IKr (dofetilide/ibutilide) in electrically remodeled atria of the goat , Circulation (2003);108 (Suppl): pp. IV-84.
  17. Stroke Prevention in Atrial Fibrillation Study , Circulation (1991);84: pp. 527-539.
    Crossref | PubMed
  18. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study , Lancet (1994);343: pp. 687-691.
    PubMed
  19. Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial , Lancet (1996);348: pp. 633-681.
    Crossref | PubMed
  20. Barile L, Messina E, Smith R et al., Engraftment, Migration And Functional Improvement In Ischemic Mouse. Hearts Injected With Human Cardiosphere-derived Stem Cells , Circ Res (2005);97; pp. 1199-1206 abstract 5011.
  21. Barth AS, Merk S,Arnoldi E et al., Reprogramming of the human atrial transcriptome in permanent atrial fibrillation: expression of a ventricular-like genomic signature , Circ Res (2005);96(9): pp. 1022-1029.
    Crossref | PubMed
  22. Mozaffarian D, Psaty BM, Rimm EB et al., Fish intake and risk of incident atrial fibrillation , Circulation (2004);110: pp. 368-373.
    Crossref | PubMed
  23. Harrison RA, Elton PJ, Is there a role for long-chain omega3 or oil-rich fish in the treatment of atrial fibrillation? , Med Hypotheses (2005);64: pp. 59-63.
    Crossref | PubMed
  24. Calo L, Bianconi L, Colivicchi F et al., N-3 fatty acids for the prevention of atrial fibrillation after coronary artery bypass surgery: a randomized, controlled trial , J Am Coll Cardiol (2005);45: pp. 1723-1728.
    Crossref | PubMed