Atrial Fibrillation Ablation Targeting Atrial Fibrosis
- Kottkamp H, Schreiber D, Moser F, Rieger A.
- Therapeutic Approaches to Atrial Fibrillation Ablation Targeting Atrial Fibrosis. JACC Clin Electrophysiol 2017;3:643-653.
The following are 10 points to remember from this review of atrial fibrosis as a potential guide for ablation of atrial fibrillation (AF):
- There often is discordance between the AF duration and burden and the amount of atrial fibrosis.
- It is likely that the extensive biatrial fibrosis that can be found in some patients early on in the course of their AF is a result of fibrotic atrial cardiomyopathy (FACM).
- The degree of FACM could explain why some patients have a low burden of paroxysmal AF for many years, whereas other patients go directly into persistent AF without ever having paroxysmal AF.
- Well-demarcated areas of marked fibrosis are more commonly found than a pattern of diffuse severe fibrosis.
- Atrial fibrosis is a major predictor of recurrent AF in patients who have undergone pulmonary vein isolation (PVI).
- The fibrotic substrate can be used to design a tailored AF ablation strategy.
- This approach requires voltage mapping during sinus rhythm using an electroanatomical mapping system.
- The following classification system for fibrosis is proposed: severe, <0.5 mV; mild/moderate, 0.5-1.5 mV; normal, >1.5 mV. Scar is defined by the absence of discrete electrograms and local capture during pacing.
- A fibrosis-guided ablation strategy consists of circumferential PVI followed by circumferential isolation of regions of severe fibrosis, then ablation lines connecting these regions to the PVI lines.
- The early experience with fibrosis-guided ablation of AF suggests that it improves efficacy compared with PVI by itself. However, randomized clinical trials are needed to demonstrate the incremental clinical value of this approach.
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