[Non-pharmacological treatment of arterial fibrillation]

In selected patients with atrial fibrillation and severe symptoms, non-pharmacological treatment may be an alternative or supplement to medical therapy. Atrioventricular nodal radiofrequency ablation (requires pacemaker implantation), or atrial pacing for sick sinus syndrome, are established treatment modalities. All other non-pharmacological therapies for atrial fibrillation are still experimental. After the "Maze" operation, atrial depolarisation has to follow one specific path determined by surgical scars in the myocardium. This prevents new episodes of atrial fibrillation, but at the cost of perioperative morbidity and mortality. Catheter-based "Maze-like" radiofrequency ablation is technically difficult, and thromboembolic complications may occur. Paroxysmal atrial fibrillation is sometimes initiated by spontaneous depolarisations in a pulmonary vein inlet. Radiofrequency ablation against such focal activity has been reported with high therapeutic success, but the results must be confirmed by several centres. For ventricular rate control, most electrophysiologists presently prefer ablation to induce a complete atrioventricular conduction block (with pacemaker) rather than trying to modify conduction by incomplete block. Atrial or dual chamber pacing may prevent bradycardia-induced atrial fibrillation. It remains to be confirmed that biatrial or multisite right atrial pacing prevents atrial fibrillation more efficiently than ordinary right atrial pacing. An atrial defibrillator is able to diagnose and convert atrial fibrillation. The equipment is expensive, and therapy without sedation may be unpleasant beyond tolerability.