Ablation of Paroxysmal Atrial Fibrillation: between Present and Future

Abstract

Pulmonary vein isolation (PVI) is the established cornerstone for atrial fibrillation (AF) ablation, indeed current guidelines recognize PVI as the gold standard for first-time AF ablation, regardless of if it is paroxysmal or persistent. Since 1998 when Haïssaguerre pioneered AF ablation demonstrating a burden reduction after segmental pulmonary vein (PV) ablation, our approach to PVI was superior in terms of methodology and technology. This review aims to describe how paroxysmal atrial fibrillation ablation has evolved over the last twenty years. We will focus on available techniques, a mechanistic understanding of paroxysmal AF genesis and the possibility of a tailored approach for the treatment of AF, before concluding with a future perspective.

Keywords: catheter ablation; paroxysmal atrial fibrillation; rhythm control.

Fig. 1.

Paroxysmal AF pathophysiology. The Coumel’s triangle shows the interplay of triggers, modulating factors and substrate in the genesis and perpetuation of atrial fibrillation whose treatment should consider a “holistic approach” aiming to correct risk factors, cardiomyopathy and comorbidities. PVs, pulmonary veins; PAF, paroxysmal atrial fibrillation; PeAF, persistent atrial fibrillation; ANS, autonomic nervous system.

Fig. 2.

Progress in paroxysmal AF treatment. Starting from 1998, the timeline shows a schematic overview of strategies and technologies developed in the past 2 decades and ongoing for AF ablation. AF, atrial fibrillation.