Recent Advances in Catheter Ablation for Atrial Fibrillation and Non-pharmacological Stroke Prevention

Atrial Fibrillation is a common arrhythmia affecting 6 million people in the United States and 33 million people worldwide, associated with significant morbidity. Whereas restoration and maintenance of sinus rhythm can translate into clinical benefit, early intervention in course of the disease can influence success and efficacy of intervention has been speculative and uncertain over past decade despite several literature and scientific studies. During past three decades catheter and surgical ablation of AF have evolved from an investigational status to a widely offerred definitive treatment now. With recent advances in mapping technology, ablation energy delivery, better understanding of pathogenesis and mechanism of AF there has been a paradigm shift in clinical decision making, patient selection, patient-physician discussion about various rhythm control strategy due to an ever improving safety and efficacy of the procedure. In this chapter we will briefly review the landmark clinical trials that has changed the outlook towards rhythm control strategy beginning from early trials such as AFFIRM, telling us rhythm control was no better than rate control to recent studies and EAST AFNET, which showed benefits of rhythm control. We will discuss differences in ablation strategy, safety and efficacy between paroxysmal AF vs. Persistent/Longstanding Persistent AF from a trigger and substrate view and pulmonary vein and non pulmonary vein targets for ablation. We will also elaborate on different energy sources for ablation such as Radiofrequency (RF), Cryoablation, newer ablation techniques such as Vein of Marshall alcohol ablation, High Power short duration ablation, Pulsed Field Ablation, Surgical ablation and Hybrid Convergent Ablation etc. Since this chapter is mostly intended towards diagnosis and management of AF in twenty-first century, authors have restricted mainly to recent developments only and purposefully have not expanded on already established preexisting knowledge about topics such as pharmacological rhythm control, rate control, Atrio-Ventricular node ablation with pacemaker implantation, direct current cardio version etc. In conclusion, with recent emerging evidence, importance of rhythm control is being increasingly recognized. Catheter ablation is more commonly performed with improving safety and efficacy. There are newer technology and ablation strategy available and should be offered to patient while discussing a comprehensive management of AF with careful review of risk benefit analysis.