Non-pharmacological treatment of atrial fibrillation

Abstract

In selected patients with atrial fibrillation and severe symptoms, non-pharmacological treatment may be an alternative or supplement to drug therapy. Atrioventricular nodal radiofrequency ablation (requires pacemaker implantation), or atrial pacing for sick sinus syndrome, are established treatment modalities. All other non-pharmacological therapies for atrial fibrillation are still experimental. After the Maze operation, atrial depolarization has to follow one specific path determined by surgical scars in the myocardium. This prevents new episodes of atrial fibrillation, but at a cost of perioperative morbidity and mortality. Catheter-based "Maze-like" radiofrequency ablation is technically difficult, and thrombo-embolic complications may occur. Paroxysmal atrial fibrillation sometimes is initiated by spontaneous depolarizations in a pulmonary vein inlet. Radio frequency ablation against such focal activity has been reported with high therapeutic success, but the results await confirmation from several centres. For ventricular rate control, most electrophysiologists presently prefer ablation to induce a complete atrioventricular conduction block (with pacemaker) rather than trying to modify conduction by incomplete block. Atrial or dual chamber pacing may prevent atrial fibrillation induced by bradycardia. It remains to confirm that biatrial or multisite right atrial pacing prevents atrial fibrillation more efficiently than ordinary right atrial pacing. An atrial defibrillator is able to diagnose and convert atrial fibrillation. The equipment is expensive, and therapy without sedation may be unpleasant beyond tolerability.

Figure 1

Schematic drawing of the right and left atria viewed from behind (below) or in front (above), with an indication of the surgical incisions that are created during Maze III operation. Compared to the original Maze procedure, the incisions in the right atrium are slightly modified to avoid damage to the blood supply of the sinus node [42]

Figure 2

Schematic drawing of the right atrium and the three ablation lines posteriorly (1), horizontally on the lateral wall (2), and anteriorly (3) that were described in the first case published about curative treatment of atrial fibrillation by radiofrequency ablation [28]. This patient previously had been subjected to an inferior caval vein-tricuspid valve isthmus ablation due to atrial flutter.