Non-pharmacological treatment of atrial fibrillation

In the last decade various non-pharmacological treatments for the cure of atrial fibrillation (AF) have been proposed. These may be divided into only palliative (i.e. pacing therapy or atrioventricular node ablation)--since it does not influence the factors favoring AF persistence--or radical with the aim to eliminate the factors causing AF with the goal of preventing its recurrences. This can be achieved either by eliminating the trigger responsible for the initiation or by modifying the substrate that permits the maintenance of the arrhythmia or both. Surgical results clearly show how, in a higher percentage of cases, it is possible to cure AF by modifying the substrate. Nowadays, this should be performed in almost every patient with permanent or paroxysmal AF who is submitted to heart surgery, while it is not yet time to extend this technique to patients with idiopathic AF. Percutaneous catheter ablation has not yet reached optimal results. The elimination of triggers seems to be the first step in patients with idiopathic lone AF; this may be accomplished by electrically isolating the pulmonary veins and when possible by directly eliminating extrapulmonary foci if present. The results of this technique were relatively good but still need to be improved. In case of permanent AF or in the presence of atrial enlargement, the removal of the triggers alone is not enough to eliminate the arrhythmia since the substrate anomalies seem to play a more important role in its maintenance than the trigger itself. Ablative therapy of AF is a technique that still needs further improvement before it may be considered a definite approach and it is still to be proposed only to selected patients with drug-resistant and poorly tolerated AF.