Catheter ablation for atrial fibrillation: mechanism-based curative treatment

The considerable cumulative morbidity and mortality burden resulting from atrial fibrillation has prompted renewed efforts to seek curative and widely applicable therapies. Currently used drugs are not only frequently ineffective at eliminating fibrillation, but may actually be life threatening. Extensive surgery involving both atria has shown that atrial fibrillation can be eliminated in most, if not all, patients, but at a significant cost. The recent discovery of the pivotal role that myocardial extensions into the pulmonary veins play in the initiation, and probably also the maintenance, of atrial fibrillation, has provided a relatively limited target conducive to catheter-based interventions. In experienced hands, paroxysmal atrial fibrillation can be eliminated in more than 85% of patients by a percutaneous intervention lasting less than 3 h with an attendant nonlethal complication risk of 1 to 2%. Thromboembolic complications and pulmonary vein stenosis are the principal complications that may result from this treatment, but their incidence is decreasing. Success rates in patients with persistent or permanent atrial fibrillation are lower, and it is anticipated that increased understanding of the underlying mechanisms will allow doctors to identify those subsets with the greatest potential for benefit from percutaneous catheter-based interventions. Such progress may allow doctors to extend the benefits of eliminating atrial fibrillation to the widest possible range of patients with this recalcitrant disorder.