Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
[Applied Cardiopulmonary Pathophysiology 16: 143-153, 2012]
Management of atrial fibrillation (AF) regarding new diagnostic and therapeutic tools has constantly evolved over the last years.
For paroxysmal AF, implantable loop recorders offer new options for better assessment of AF burden. For treatment, pulmonary vein (PV) isolation has evolved an accepted, effective treatment with ~75-85% of patients in stable sinus rhythm. Since the rate of major complications of 2.5% is relatively low, PV isolation is nowadays the first choice therapy for symptomatic patients with drug-resistant paroxysmal AF. To reduce the most frequent reason for AF recurrence after PV isolation, i.e. reconnection of formerly isolated PV, new techniques including pharmacological testing for dormant PV connection and more precise testing for incomplete ablation lines by pacing manoeuvres have been introduced. New ablation tools include contact force measuring catheters for larger and more durable lesions by better catheter tip to tissue contact, and balloon-shaped ablation catheters providing single shot PV isolation using cryo-energy or laser applications.
For persistent AF, assessment of the atrial substrate maintaining AF by 3-dimensional magnetic resonance imaging (3D MRI) has the potential to predict ablation outcome. For the treatment of symptomatic persistent AF, the best ablation approach is a matter of debate, with linear ablation concepts competing with the ablation of complex fractionated atrial electrograms (CFAE). The combination of both techniques seems to provide the best results, with 65-80% of patients in stable sinus rhythm. These favourable results, however, are only reached after 2-3 ablation procedures.
For new antiarrhythmic drugs, dronedarone has widely deceived the high hopes, revealing considerable liver toxicity, increased mortality for some AF patients’ subgroups and sobering antiarrhythmic effect when compared to amiodarone for the suppression of AF. New oral anticoagulants which act by direct inhibition of thrombin or factor X are promising and are expected to facilitate considerably future clinical practice. In large trials, they were found to be comparable or better than warfarin regarding the incidence of ischemic stroke and major bleedings including intracranial bleeding.
Key words: atrial fibrillation, medical treatment, pulmonary vein isolation
Address for correspondence:
Isabel Deisenhofer, M.D., Ph.D.
Deutsches Herzzentrum München
Technische Universität München