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Review
. 2021 Jul 15;10(14):3129.
doi: 10.3390/jcm10143129.

Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies

Riyaz A Kaba  1   2 , Aziz Momin  1   2 , John Camm  1
Affiliations
Review

Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies

Riyaz A Kaba et al. J Clin Med. .

Abstract

Atrial fibrillation (AF) is a global disease with rapidly rising incidence and prevalence. It is associated with a higher risk of stroke, dementia, cognitive decline, sudden and cardiovascular death, heart failure and impairment in quality of life. The disease is a major burden on the healthcare system. Paroxysmal AF is typically managed with medications or endocardial catheter ablation to good effect. However, a large proportion of patients with AF have persistent or long-standing persistent AF, which are more complex forms of the condition and thus more difficult to treat. This is in part due to the progressive electro-anatomical changes that occur with AF persistence and the spread of arrhythmogenic triggers and substrates outside of the pulmonary veins. The posterior wall of the left atrium is a common site for these changes and has become a target of ablation strategies to treat these more resistant forms of AF. In this review, we discuss the role of the posterior left atrial wall in persistent and long-standing persistent AF, the limitations of current endocardial-focused treatment strategies, and future perspectives on hybrid epicardial-endocardial approaches to posterior wall isolation or ablation.

Keywords: convergent ablation; hybrid ablation; persistent atrial fibrillation; posterior wall.

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Conflict of interest statement

R. A. Kaba is a consultant for Daiichi Sankyo, Bayer, Atricure and Biotronik. A. Momin is a consultant for Atricure. A. J. Camm has received personal fees from Abbott, Boston Scientific, Medtronic and Atricure.

Figures

Figure 1
Figure 1
Risk factors for perpetuation of AF. Modifiable risk factors are highlighted separately. LSPersAF, long-standing persistent AF; LA, left atrium; PWD, p-wave duration; LVH, left ventricular hypertrophy; BMI, body mass index; OSA, obstructive sleep apnoea; DM, diabetes mellitus.
Figure 2
Figure 2
Triggers and substrates for PAF vs. PersAF. In PAF, the majority of these are located within and around the PVs, whereas in PersAF there are many more non-PV locations, especially in the posterior wall (between the four PVs and below the lower PVs). LA, left atrium; LAA, left atrial appendage; RA, right atrium; RAA, right atrial appendage; SVC, superior vena cava; IVC, inferior vena cava.
See this image and copyright information in PMC

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