Present concepts in management of atrial fibrillation: From drug therapy to ablation

Abstract

Atrial fibrillation (AF) management requires knowledge of its pattern of presentation, underlying conditions, and decisions about restoration and maintenance of sinus rhythm, control of the ventricular rate, and anti-thrombotic therapy. Maintenance of sinus rhythm is a desirable goal in AF patients because the prevention of recurrence may improve cardiac function, relieve symptoms and reduce the likelihood of adverse events. Anti-arrhythmic drug therapy is the first-line treatment for patients with paroxysmal and persistent AF based on current guidelines. However, currently used drugs have limited efficacy and cause cardiac and extracardiac toxicity. Thus, there is a continued need to develop new drugs, device and ablative approaches to rhythm management. Additionally, simpler and safer stroke prevention regimens are needed for AF patients on life-long anticoagulation, including occlusion of the left atrial appendage. The results of the Randomized Evaluation of Long-Term Anticoagulant Therapy study are encouraging in these settings. Knowledge on the pathophysiology of AF is rapidly expanding and identification of focally localized triggers has led to the development of new treatment options for this arrhythmia. Conversely, the clinical decision whether to restore and maintain sinus rhythm or simply control the ventricular rate has remained a matter of intense debate. In the minority of patients in whom AF cannot be adequately managed by pharmacological therapy, the most appropriate type of non-pharmacological therapy must be selected on an individualized basis. Curative treatment of AF with catheter ablation is now a legitimate option for a large number of patients. The evolution of hybrid therapy, in which two or more different strategies are employed in the same patient, may be an effective approach to management of AF. In any case, planning a treatment regimen for AF should include evaluation of the risks inherent in the use of various drugs as well as more invasive strategies.

Keywords: Antiarrhythmic medications; Atrial fibrillation; Catheter ablation.

Figure 1

Various approaches to cure atrial fibrillation. A-C: most procedures used for ablation of atrial fibrillation (AF) include one or a combination of the techniques. A: Isolation of the pulmonary veins (PVs) with or without demonstration of PV-left atrial conduction block; B: PVI with additional left atrial linear ablations (mitral isthmus and roof); C: Ablation of the complex fractionated atrial electrograms (CFAE). The shaded areas indicate CFAE. D: Illustration of atrial lesions in the modified Cox/MAZE III procedure. Violet tags indicate the anatomic location of the lesions. IVC: Inferior vena cava; LAA: Left atrial appendage; LI: Left inferior pulmonary vein; LS: Left superior pulmonary vein; PVI: Pulmonary vein isolation; RI: Right inferior pulmonary vein; RS: Right superior pulmonary vein; SVC: Superior vena cava; RAA: Right atrial appendage.