Progress in atrial fibrillation ablation during 25 years of Europace journal

Abstract

The first edition of Europace journal in 1999 came right around the time of the landmark publication of the electrophysiologists from Bordeaux, establishing how elimination of ectopic activity from the pulmonary veins (PVs) resulted in a marked reduction of atrial fibrillation (AF). The past 25 years have seen an incredible surge in scientific interest to develop new catheters and energy sources to optimize durability and safety of ablation, as well as study the mechanisms for AF and devise ablation strategies. While ablation in the beginning was performed with classic 4 mm tip catheters that emitted radiofrequency (RF) energy to create tissue lesions, this evolved to using irrigation and contact force (CF) measurement while increasing power. Also, so-called single-shot devices were developed with balloons and arrays to create larger contiguous lesions, and energy sources changed from RF current to cryogenic ablation and more recently pulsed field ablation with electrical current. Although PV ablation has remained the basis for every AF ablation, it was soon recognized that this was not enough to cure all patients, especially those with non-paroxysmal AF. Standardized approaches for additional ablation targets have been used but have not been satisfactory in all patients so far. This led to highly technical mapping systems that are meant to unravel the drivers for the maintenance of AF. In the following sections, the development of energies, strategies, and tools is described with a focus on the contribution of Europace to publish the outcomes of studies that were done during the past 25 years.

Keywords: Ablation; Atrial fibrillation; Cryoablation; Mapping; Pulsed field ablation; Radiofrequency.

Graphical abstract

Figure 1

Evolution over 20 years towards a standardized and reproducible RF-PVI approach associated with an excellent efficacy/safety balance (the ‘CLOSE’ protocol; Europace 2018).

Figure 2

Different modalities to deliver high-power short-duration (HPSD) and very high-power very short-duration (vHPvSD) RF with re-introduction of temperature control in the era of irrigated RF ablation. The CLOSE protocol using HPSD and vHPvSD shortens the procedure time while preserving the excellent efficacy/safety balance.

Figure 3

New catheters to deliver ablation for AF.

Figure 4

Top panels show MRI measurements at different stages before and after PFA. Middle panels show voltage maps before and acutely and chronically after PFA. Bottom panels show strain patterns before and acutely and chronically after PFA.

Figure 5

Examples of typical substrate ablation strategies beyond PVI. From: Eur Heart J, Volume 31, Issue 11, June 2010, Pages 1344–1356, https://doi.org/10.1093/eurheartj/ehq041.

Figure 6

(A) Posterior wall ablation strategy. (B) Ablation within the margins of the posterior box (representative of extensive or limited ablation within box). LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein. From Europace, Volume 19, Issue 12, December 2017, Pages 1958–1966, https://doi.org/10.1093/europace/euw231.

Figure 7

(A and B) See legend in the figure. From AFACART: Knecht, S., et al., Multicenter evaluation of non-invasive biatrial mapping for persistent atrial fibrillation ablation: the AFACART study. Europace, 2017. 19(8): p. 1302–1309.

Figure 8

See legend in the figure. From Lin, T., et al., Focal impulse and rotor modulation using the novel 64-electrode basket catheter: electrogram characteristics of human rotors. Europace, 2015. 17(12): p. 1791–7.