MODERN METHODS OF CATHETER TREATMENT OF ATRIAL FIBRILLATION. CURRENT STATUS OF THE ISSUE

Highlights
An overview of the latest literature data on the evidence base of invasive treatment of atrial fibrillation
using pulmonary vein isolation and additional effects on the left atrium is presented.

Summary

Atrial fibrillation (AF) is currently the most common arrhythmia encountered in clinical practice. The number of patients is rapidly increasing and over the past 50 years the prevalence of the disease has shown a threefold increase. Despite its non-infectious nature, experts equate the disease to the epidemic of the current century. It has been reliably proven that AF contributes to the development and progression of such dangerous conditions as chronic heart failure, stroke, pulmonary embolism, and arrhythmogenic cardiomyopathy. A rhythm control strategy not only helps relieve arrhythmia symptoms, reducing the burden of patients with AF, but also prevents the diseases described above. Based on the results of current data, catheter-based techniques for the treatment of atrial fibrillation show better efficacy results compared to drug therapy. At the moment, the question of the technique of performing the ablation procedure for different forms of atrial fibrillation remains open. An urgent aspect remains increasing the effectiveness of interventions in different groups of patients. There are both established techniques for isolating the pulmonary veins, with proven effectiveness in numerous studies, and new directions for improving the procedure, including isolation of the posterior wall of the left atrium, additional effects on the autonomic ganglion plexuses, complex fragmented electrograms and isolation of the superior vena cava. The review article presents a variety of intervention options, in accordance with the form of atrial fibrillation and its mechanisms of pathogenesis, as well as data from recent studies reflecting the influence of additional interventions in the left atrium on the effectiveness of the intervention. Ablation techniques are described in detail, taking into account the constant improvement of the medical devices used and the desire to standardize the procedure. Also presented are current diagnostic methods aimed at the most accurate detection of episodes of fibrillation and an objective assessment of the effectiveness of the treatment.

1. Brasca FMA, Menè R, Perego GB. Catheter Ablation for Atrial Fibrillation in Structural Heart Disease: A Review. J Clin Med. 2023 Feb 10;12(4):1431. doi: 10.3390/jcm12041431.

2. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation. 2019 Mar 5;139(10):e56-e528. doi: 10.1161/CIR.0000000000000659.

3. Schnabel RB, Yin X, Gona P, Larson MG, Beiser AS, McManus DD, Newton-Cheh C, Lubitz SA, Magnani JW, Ellinor PT, Seshadri S, Wolf PA, Vasan RS, Benjamin EJ, Levy D. 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study. Lancet. 2015 Jul 11;386(9989):154-62. doi: 10.1016/S0140-6736(14)61774-8.

4. Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Abhayaratna WP, Seward JB, Tsang TS. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation. 2006 Jul 11;114(2):119-25. doi: 10.1161/CIRCULATIONAHA.105.595140.

5. Di Carlo A, Bellino L, Consoli D, Mori F, Zaninelli A, Baldereschi M, Cattarinussi A, D'Alfonso MG, Gradia C, Sgherzi B, Pracucci G, Piccardi B, Polizzi B, Inzitari D; National Research Program: Progetto FAI. La Fibrillazione Atriale in Italia. Prevalence of atrial fibrillation in the Italian elderly population and projections from 2020 to 2060 for Italy and the European Union: the FAI Project. Europace. 2019 Oct 1;21(10):1468-1475. doi: 10.1093/europace/euz141.

6. Chiang CE, Wang KL, Lip GY. Stroke prevention in atrial fibrillation: an Asian perspective. Thromb Haemost. 2014 May 5;111(5):789-97. doi: 10.1160/TH13-11-0948.

7. Polyakov D.S., Fomin I.V., Belenkov Yu.N., Mareev V.Yu., Ageev F.T., Artemjeva E.G., Badin Yu.V., Bakulina E.V., Vinogradova N.G., Galyavich A.S., Ionova T.S., Kamalov G.M., Kechedzhieva S.G., Koziolova N.A., Malenkova V.Yu., Malchikova S.V., Mareev Yu.V., Smirnova E.A., Tarlovskaya E.I., Shcherbinina E.V., Yakushin S.S. Chronic heart failure in the Russian Federation: what has changed over 20 years of follow-up? Results of the EPOCH-CHF study. Kardiologiia. 2021;61(4):414. (In Russ) doi:10.18087/cardio.2021.4. n1628

8. Shapkina M.Yu., Mazdorova E.V., Avdeeva E.M., Shcherbakova L.V., Ryabikov A.N., Hubachek J.A., Bobak M., Malyutina S.K. Changes in the prevalence of atrial fibrillation in the Russian population over a 13-year follow-up. Cardiovascular Therapy and Prevention. 2022;21(8):3108. (In Russ.) doi:10.15829/1728-8800-2022-3108

9. Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, D'Agostino RB, Massaro JM, Beiser A, Wolf PA, Benjamin EJ. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004 Aug 31;110(9):1042-6. doi: 10.1161/01.CIR.0000140263.20897.42.

10. Mou L, Norby FL, Chen LY, O'Neal WT, Lewis TT, Loehr LR, Soliman EZ, Alonso A. Lifetime Risk of Atrial Fibrillation by Race and Socioeconomic Status: ARIC Study (Atherosclerosis Risk in Communities). Circ Arrhythm Electrophysiol. 2018 Jul;11(7): e006350. doi: 10.1161/CIRCEP.118.006350.

11. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GY, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg. 2016 Nov;50(5): e1-e88. doi: 10.1093/ejcts/ezw313.

12. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. doi: 10.1093/eurheartj/ehaa612.

13. Arakelyan M.G., Bockeria L.A., Vasilieva E.Yu., Golitsyn S.P., Golukhova E.Z., Gorev M.V., Davtyan K.V., Drapkina O.M., Kropacheva E.S., Kuchinskaya E.A., Lajovich L.Yu., Mironov N.Yu., Mishina I.E., Panchenko E.P., Revishvili A.Sh., Rzayev F.G., Tatarsky B.A., Utsumueva M.D., Shakhmatova O.O., Shlevkov N.B., Shpektor A.V., Andreev D.A., Artyukhina E.A., Barbarash O.L., Galyavich A.S., Duplyakov D.V., Zenin S.A., Lebedev D.S., Mikhailov E.N., Novikova N.A., Popov S.V., Filatov A.G., Shlyakhto E.V., Shubik Yu.V. 2020 Clinical guidelines for Atrial fibrillation and atrial flutter. Russian Journal of Cardiology. 2021;26(7):4594. (In Russ.) doi:10.15829/1560-4071-2021-4594

14. Calkins H, Reynolds MR, Spector P, Sondhi M, Xu Y, Martin A, Williams CJ, Sledge I. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses. Circ Arrhythm Electrophysiol. 2009 Aug;2(4):349-61. doi: 10.1161/CIRCEP.108.824789.

15. Zimetbaum P. Amiodarone for atrial fibrillation. N Engl J Med. 2007 Mar 1;356(9):935-41. doi: 10.1056/NEJMct065916.

16. Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace. 2012 Apr;14(4):528-606. doi: 10.1093/europace/eus027.

17. Ruaengsri C, Schill MR, Khiabani AJ, Schuessler RB, Melby SJ, Damiano RJ Jr. The Cox-maze IV procedure in its second decade: still the gold standard? Eur J Cardiothorac Surg. 2018 Apr 1;53(suppl_1): i19-i25. doi: 10.1093/ejcts/ezx326.

18. Haïssaguerre M, Jaïs P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, Le Mouroux A, Le Métayer P, Clémenty J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998 Sep 3;339(10):659-66. doi: 10.1056/NEJM199809033391003.

19. Jaïs P, Haïssaguerre M, Shah DC, Chouairi S, Gencel L, Hocini M, Clémenty J. A focal source of atrial fibrillation treated by discrete radiofrequency ablation. Circulation. 1997 Feb 4;95(3):572-6. doi: 10.1161/01.cir.95.3.572.

20. Pappone C, Rosanio S, Oreto G, Tocchi M, Gugliotta F, Vicedomini G, Salvati A, Dicandia C, Mazzone P, Santinelli V, Gulletta S, Chierchia S. Circumferential radiofrequency ablation of pulmonary vein ostia: A new anatomic approach for curing atrial fibrillation. Circulation. 2000 Nov 21;102(21):2619-28. doi: 10.1161/01.cir.102.21.2619.

21. Wittkampf FH, Nakagawa H. RF catheter ablation: Lessons on lesions. Pacing Clin Electrophysiol. 2006 Nov;29(11):1285-97. doi: 10.1111/j.1540-8159.2006.00533. x.

22. Taghji P, El Haddad M, Phlips T, Wolf M, Knecht S, Vandekerckhove Y, Tavernier R, Nakagawa H, Duytschaever M. Evaluation of a Strategy Aiming to Enclose the Pulmonary Veins with Contiguous and Optimized Radiofrequency Lesions in Paroxysmal Atrial Fibrillation: A Pilot Study. JACC Clin Electrophysiol. 2018 Jan;4(1):99-108. doi: 10.1016/j.jacep.2017.06.023.

23. Park CI, Lehrmann H, Keyl C, Weber R, Schiebeling J, Allgeier J, Schurr P, Shah A, Neumann FJ, Arentz T, Jadidi AS. Mechanisms of pulmonary vein reconnection after radiofrequency ablation of atrial fibrillation: the deterministic role of contact force and interlesion distance. J Cardiovasc Electrophysiol. 2014 Jul;25(7):701-8. doi: 10.1111/jce.12396.

24. Nakagawa H, Jackman WM. The Role of Contact Force in Atrial Fibrillation Ablation. J Atr Fibrillation. 2014 Jun 30;7(1):1027. doi: 10.4022/jafib.1027.

25. Hussein A, Das M, Riva S, Morgan M, Ronayne C, Sahni A, Shaw M, Todd D, Hall M, Modi S, Natale A, Dello Russo A, Snowdon R, Gupta D. Use of Ablation Index-Guided Ablation Results in High Rates of Durable Pulmonary Vein Isolation and Freedom From Arrhythmia in Persistent Atrial Fibrillation Patients: The PRAISE Study Results. Circ Arrhythm Electrophysiol. 2018 Sep;11(9): e006576. doi: 10.1161/CIRCEP.118.006576.

26. Gage AA, Baust JM, Baust JG. Experimental cryosurgery investigations in vivo. Cryobiology. 2009 Dec;59(3):229-43. doi: 10.1016/j.cryobiol.2009.10.001.

27. Straube F, Dorwarth U, Schmidt M, Wankerl M, Ebersberger U, Hoffmann E. Comparison of the first and second cryoballoon: high-volume single-center safety and efficacy analysis. Circ Arrhythm Electrophysiol. 2014 Apr;7(2):293-9. doi: 10.1161/CIRCEP.113.000899.

28. Zhou X, Lv W, Zhang W, Ye Y, Li Y, Zhou Q, Zhang J, Xing Q, Lu Y, Zhang L, Wang H, Qin W, Tang B. Comparative efficacy and safety of contact force-sensing catheter and second-generation cryoballoon ablation for atrial fibrillation: a meta-analysis. Braz J Med Biol Res. 2017 Aug 7;50(9): e6409. doi: 10.1590/1414-431X20176409.

29. Andrade JG, Deyell MW, Badra M, Champagne J, Dubuc M, Leong-Sit P, Macle L, Novak P, Roux JF, Sapp J, Tang A, Verma A, Wells GA, Khairy P. Randomised clinical trial of cryoballoon versus irrigated radio frequency catheter ablation for atrial fibrillation-the effect of double short versus standard exposure cryoablation duration during pulmonary vein isolation (CIRCA-DOSE): methods and rationale. BMJ Open. 2017 Oct 5;7(10):e017970. doi: 10.1136/bmjopen-2017-017970.

30. Wijesurendra RS, Casadei B. Mechanisms of atrial fibrillation. Heart. 2019 Dec;105(24):1860-1867. doi: 10.1136/heartjnl-2018-314267.

31. Sicouri S, Blazek J, Belardinelli L, Antzelevitch C. Electrophysiological characteristics of canine superior vena cava sleeve preparations: effect of ranolazine. Circ Arrhythm Electrophysiol. 2012 Apr;5(2):371-9. doi: 10.1161/CIRCEP.111.969493.

32. Higuchi K, Yamauchi Y, Hirao K, Sasaki T, Hachiya H, Sekiguchi Y, Nitta J, Isobe M. Superior vena cava as initiator of atrial fibrillation: factors related to its arrhythmogenicity. Heart Rhythm. 2010 Sep;7(9):1186-91. doi: 10.1016/j.hrthm.2010.05.017.

33. Corrado A, Bonso A, Madalosso M, Rossillo A, Themistoclakis S, Di Biase L, Natale A, Raviele A. Impact of systematic isolation of superior vena cava in addition to pulmonary vein antrum isolation on the outcome of paroxysmal, persistent, and permanent atrial fibrillation ablation: results from a randomized study. J Cardiovasc Electrophysiol. 2010 Jan;21(1):1-5. doi: 10.1111/j.1540-8167.2009.01577. x.

34. Krivosheev Yu. S., Bashta D.I., Simonyan A.A., Krasilnikova S.Yu., Vilenskiy L.I., Myznikova T.A., Mishodzheva Z.A., Kolesnikov V.N. Ganglionated plexi ablation with pulmonary vein isolation after testing dormant pulmonary vein conduction and excluding non-pulmonary triggers in patients with paroxysmal atrial fibrillation. Patologiya krovoobrashcheniya i kardiokhirurgiya = Circulation Pathology and Cardiac Surgery. 2018;22(3):25-38. (In Russ.). doi: 10.21688-1681-3472-2018-3-25-38

35. Colvin E.V. Cardiac embryology. In: Garson A. Jr., editor. The Science and Practice of Pediatric Cardiology. 2nd ed. Lippincott Williams & Wilkins; Baltimore, MD, USA: 1998. pp. 91–126.

36. Kaba RA, Momin A, Camm J. Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies. J Clin Med. 2021 Jul 15;10(14):3129. doi: 10.3390/jcm10143129.

37. Kozlov AV, Durmanov SS, Bazylev VV. Left atrial posterior wall isolation in persistent atrial fibrillation does not influence the efficacy of catheter ablation: a pilot study. Journal of Arrhythmology. 2022;29(3): 5-12. (In Russ.). doi: 10.35336/VA-2022-3-01

38. Nademanee K, Oketani N. The role of complex fractionated atrial electrograms in atrial fibrillation ablation moving to the beat of a different drum. J Am Coll Cardiol. 2009 Mar 3;53(9):790-1. doi: 10.1016/j.jacc.2008.11.022.

39. Mateos JC, Mateos EI, Lobo TJ, Pachón MZ, Mateos JC, Pachón DQ, Vargas RN, Piegas LS, Jatene AD. Radiofrequency catheter ablation of atrial fibrillation guided by spectral mapping of atrial fibrillation nests in sinus rhythm. Arq Bras Cardiol. 2007 Sep;89(3):124-34, 140-50. English, Portuguese. doi: 10.1590/s0066-782x2007001500001.

40. Oral H, Chugh A, Yoshida K, Sarrazin JF, Kuhne M, Crawford T, Chalfoun N, Wells D, Boonyapisit W, Veerareddy S, Billakanty S, Wong WS, Good E, Jongnarangsin K, Pelosi F Jr, Bogun F, Morady F. A randomized assessment of the incremental role of ablation of complex fractionated atrial electrograms after antral pulmonary vein isolation for long-lasting persistent atrial fibrillation. J Am Coll Cardiol. 2009 Mar 3;53(9):782-9. doi: 10.1016/j.jacc.2008.10.054.

41. Verma A, Jiang CY, Betts TR, Chen J, Deisenhofer I, Mantovan R, Macle L, Morillo CA, Haverkamp W, Weerasooriya R, Albenque JP, Nardi S, Menardi E, Novak P, Sanders P; STAR AF II Investigators. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med. 2015 May 7;372(19):1812-22. doi: 10.1056/NEJMoa1408288.

42. Lupercio F, Lin AY, Aldaas OM, Romero J, Briceno D, Hoffmayer KS, Han FT, Di Biase L, Feld GK, Hsu JC. Role of adjunctive posterior wall isolation in patients undergoing atrial fibrillation ablation: a systematic review and meta-analysis. J Interv Card Electrophysiol. 2020 Jun;58(1):77-86. doi: 10.1007/s10840-019-00634-8.

43. Sau A, Al-Aidarous S, Howard J, Shalhoub J, Sohaib A, Shun-Shin M, Novak PG, Leather R, Sterns LD, Lane C, Kanagaratnam P, Peters NS, Francis DP, Sikkel MB. Optimum lesion set and predictors of outcome in persistent atrial fibrillation ablation: a meta-regression analysis. Europace. 2019 Aug 1;21(8):1176-1184. doi: 10.1093/europace/euz108.

44. Bai R, Di Biase L, Mohanty P, Trivedi C, Dello Russo A, Themistoclakis S, Casella M, Santarelli P, Fassini G, Santangeli P, Mohanty S, Rossillo A, Pelargonio G, Horton R, Sanchez J, Gallinghouse J, Burkhardt JD, Ma CS, Tondo C, Natale A. Proven isolation of the pulmonary vein antrum with or without left atrial posterior wall isolation in patients with persistent atrial fibrillation. Heart Rhythm. 2016 Jan;13(1):132-40. doi: 10.1016/j.hrthm.2015.08.019.

45. Lee JM, Shim J, Park J, Yu HT, Kim TH, Park JK, Uhm JS, Kim JB, Joung B, Lee MH, Kim YH, Pak HN; POBI-AF Investigators. The Electrical Isolation of the Left Atrial Posterior Wall in Catheter Ablation of Persistent Atrial Fibrillation. JACC Clin Electrophysiol. 2019 Nov;5(11):1253-1261. doi: 10.1016/j.jacep.2019.08.021.

46. Hanke T, Charitos EI, Stierle U, Karluss A, Kraatz E, Graf B, Hagemann A, Misfeld M, Sievers HH. Twenty-four-hour holter monitor follow-up does not provide accurate heart rhythm status after surgical atrial fibrillation ablation therapy: up to 12 months experience with a novel permanently implantable heart rhythm monitor device. Circulation. 2009 Sep 15;120(11 Suppl):S177-84. doi: 10.1161/CIRCULATIONAHA.108.838474.

47. Hindricks G, Pokushalov E, Urban L, Taborsky M, Kuck KH, Lebedev D, Rieger G, Pürerfellner H; XPECT Trial Investigators. Performance of a new leadless implantable cardiac monitor in detecting and quantifying atrial fibrillation: Results of the XPECT trial. Circ Arrhythm Electrophysiol. 2010 Apr;3(2):141-7. doi: 10.1161/CIRCEP.109.877852.

48. Verma A, Champagne J, Sapp J, Essebag V, Novak P, Skanes A, Morillo CA, Khaykin Y, Birnie D. Discerning the incidence of symptomatic and asymptomatic episodes of atrial fibrillation before and after catheter ablation (DISCERN AF): a prospective, multicenter study. JAMA Intern Med. 2013 Jan 28;173(2):149-56. doi: 10.1001/jamainternmed.2013.1561.