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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EApproximately 2.5 million patients in the United States and 3 million in Europe suffer from atrial fibrillation (AF). Due to the growing epidemic of obesity and other AF risk factors, this number is expected to grow to 16 million by the year 2050 in the US alone. Management of AF is very difficult to standardize; AF covers a wide spectrum of patients and is associated with a number of heart diseases. The contributing mechanisms have not been fully unraveled, and therefore one therapeutic modality is not universally appropriate. Understanding effective treatments of AF and how they can be improved over the next several decades is critical to lowering this looming number.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Earrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/6\/5\/7\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-834145858\u0022 data-figure-caption=\u0022\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure1\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/6\/5\/7\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/6\/5\/7\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/6\/5\/7\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/10930\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EApproximately 2.5 million patients in the United States and 3 million in Europe suffer from atrial fibrillation (AF). Due to the growing epidemic of obesity and other AF risk factors, this number is expected to grow to 16 million by the year 2050 in the US alone. Management of AF is very difficult to standarize; AF covers a wide spectrum of patients and is associated with a number of heart diseases. The contributing mechanisms have not been fully unraveled, and therefore one therapeutic modality is not universally appropriate. Understanding effective treatments of AF and how they can be improved over the next several decades is critical to lowering this looming number.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EIs there a future for antiarrhythmic drug therapy?\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThe majority of AF patients are over 65 years of age and are largely unable to endure surgical therapies. Therefore, argues Samuel Levy, MD, Chief of the Cardiology Division in the School of Medicine at H\u00f4pital Nord, Marseille, France, \u201cWe DO need pharmacologic therapy.\u201d Indeed, the AHA\/ACC\/ESC revised guidelines maintain that catheter ablation cannot be the first line of therapy. Finally, the ALFA study shows that in the \u201creal world\u201d (e.g. not in an academic institution where admitted patients are often difficult to treat), only about 30% of patients with paroxysmal AF are refractory to drug therapy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EPharmacologic therapy is useful in controlling heart rate in patients in whom AF is well tolerated or chronic, and is as effective as rhythm control. The AFFIRM trial compared rate control and anticoagulation to medical therapies aimed at rhythm control and found that survival rates were similar. Therefore, controlling either rhythm or rate appears to be a valid goal.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EOne benefit of pharmacotherapy is that a patient can self-administer the drug outside of the hospital. This \u201cpill-in-the-pocket\u201d approach was tested (Alboni P et al; \u003Cem\u003ENEJM\u003C\/em\u003E 2004; 351:2384) in a prospective study of recurrent AF where patients self-administered flecainide or propafenone. The results were very encouraging; 92% of episodes were treated effectively, there was a low rate of adverse events and a marked decrease in emergency room visits. This therapy is limited, however, to patients without ischemic heart disease or other significant structural heart disease.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EIn France, 92% of patients with AF are taking some type of antiarrhythmic drug with amiodarone being the most widely used. Although it is very effective, many side effects are associated with amiodarone administration. Therefore, an iodine-free analogue, dronedarone, was developed and is currently in phase III clinical trials. This drug, estimates Dr. Levy, \u201chas the highest chance to come to market.\u201d The DAFNE (Dronedarone Atrial Fibrillation Study After Electrical Cardioversion) trial shows that a relatively high dose of 800mg effectively controls ventricular rate with very few side effects. Other drugs in development include Tedisamil, AZD7009 (Atrial Repolarization Delaying Agent; now in phase II testing) and CVT-510 (an A1 adenosine receptor agonist).\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EIn summary, the first line of treatment for AF remains oral anticoagulation and pharmacologic treatment for rhythm or rate control. Future therapeutic strategies, of which there may be many per patient, should be individually selected based on a safety first approach.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EHow will catheter ablation evolve over the next 10 years?\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003ETen years ago, AF was not related to mortality and was considered virtually harmless. \u201cNow we know it is not a benign condition,\u201d remarks Giuseppe Augello, MD, from the Department of Electrophysiology, San Raffaele Scientific Institute, Milan, Italy, \u201cWe need to treat AF in an evidence-based way and the first step is with antiarrhythmic drug (AAD) therapy. Catheter ablation is considered second line therapy for patients who are resistant to AAD therapy.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EThere are many outstanding ablation techniques in use today, including pulmonary vein isolation (PVI) with a Lasso catheter, composite finite element (CFE) methods, and circumferential pulmonary vein ablation (CPVA). A recent study of 77 patients receiving CPVA showed that 74% of patients were free of recurrent atrial fibrillation or flutter without AAD therapy (Oral H et al; \u003Cem\u003ENEJM\u003C\/em\u003E 2006; 354:934). This study was limited to patients without significant structural heart disease such as low ejection fraction. In addition, while patients were followed with very careful arrhythmia monitoring the follow up was only 1 year. In the hands of the experienced operators, one third of patients required repeat ablation.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESurgical Approaches to AF\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe Cox Maze III method, an open-heart surgical procedure to eliminate atrial fibrillation, has long been the gold standard for AF surgery. However, due to the amount of surgery required and the potential adverse outcomes, it is being phased out. A new procedure developed by Randall K. Wolf, MD, a cardiothoracic surgeon with the University of Cincinnati\u0027s Department of Surgery, termed the minimaze technique, is gaining attention. This minimally invasive procedure to cure AF obviates creating a large incision in the patient\u0027s chest and does not require a heart-lung machine.\u003C\/p\u003E\n         \u003Cdiv class=\u0022boxed-text\u0022 id=\u0022boxed-text-1\u0022\u003E\u003Cbr\/\u003E\u003Cdiv class=\u0022graphic\u0022 id=\u0022graphic-2\u0022\u003E\u003Cdiv class=\u0022graphic-inline anchor\u0022\u003E\u003Cimg class=\u0022highwire-embed\u0022 alt=\u0022Embedded Image\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/highwire\/spmdc\/6\/5\/7\/embed\/graphic-2.gif\u0022\/\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-11\u0022\u003EIn the next decade Dr. Augello estimates an insurgence of new technologies to treat AF, including:\u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n                  \n                  \u003Cp id=\u0022p-12\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u2735 \u003C\/span\u003ERadio frequency ablation with irrigation\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n                  \n                  \u003Cp id=\u0022p-13\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u2735 \u003C\/span\u003ESelective ablation\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n                  \n                  \u003Cp id=\u0022p-14\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u2735 \u003C\/span\u003EReal-time MRI navigation\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n                  \n                  \u003Cp id=\u0022p-15\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u2735 \u003C\/span\u003ERobotic navigation\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n                  \n                  \u003Cp id=\u0022p-16\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u2735 \u003C\/span\u003EAutomatic ablation\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n                  \n                  \u003Cp id=\u0022p-17\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u2735 \u003C\/span\u003ENetwork implementation\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n                  \n                  \u003Cp id=\u0022p-18\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u2735 \u003C\/span\u003EIndividual pathophysiology\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n                  \n                  \u003Cp id=\u0022p-19\u0022\u003E\u003Cspan class=\u0022list-label\u0022\u003E\u2735 \u003C\/span\u003ENew ablation targets\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-20\u0022\u003E\u201cThere have been two major changes in the treatment of AF\u201d, says Dr. Wolf, \u201cFirst, treat people with concomitant AF in the operating room (most common is a microvalve procedure) and second, offer some minimally invasive procedures for the stand-alone group.\u201d The minimaze technique, which involves opening the pericardium, takes about 2.5 hours and requires few or no incisions in the actual heart. In 2005, Dr. Wolf published encouraging results on this procedure performed on 27 patients (Wolf RK et al. \u003Cem\u003EJ Thorac Cardiovasc Surg 2005; 130:797\u003C\/em\u003E). A 91% cure rate was seen in the 23 patients that were available for a 6-month follow-up. Additionally, 90% of patients were cured for paroxysmal AF and 85% were cured for continuous AF at 3 years. Dr. Wolf estimates that over 1,700 cases have been performed worldwide and there have been no documented cases of mortality.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/6\/5\/7\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-834145858\u0022 data-figure-caption=\u0022\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure2\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/6\/5\/7\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/6\/5\/7\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure2\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/6\/5\/7\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/10933\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-21\u0022\u003ECareful planning and consideration can improve the outcomes of these procedures. Dr. Wolf emphasizes the importance of using intraoperative EP testing, adding, \u201cIt is important to have the equipment so that surgeons can speak the language of the electrophysiologist.\u201d Removal of the left atrial appendage is also a very important part of Dr. Wolf\u0027s procedure. Finally, careful selection of the energy sources and surgical techniques is vital. New techniques for atrial appendage exclusion, both percutaneous and surgical are also emerging (Gillinov AM et al. \u003Cem\u003EAnn Thorac Surg\u003C\/em\u003E 2002; 74:2165 and Sievert H et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2003; 41: (Suppl II):79A).\u003C\/p\u003E\n         \u003Cp id=\u0022p-22\u0022\u003E\u201cI predict to you there will be a mushrooming of surgical data in 2007,\u201d adds Dr. Wolf when commenting on the minimally invasive techniques for AE. The advantages of these techniques are that they address plausible mechanisms, are performed somewhat easily, have few complications and involve removal of the left atrial appendage.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-5\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EHow will we be treating AF in 10 years?\u003C\/h2\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EThere are two approaches to treating AF, explains Gordon Tomaselli, MD, Professor of Medicine in the Department of Cardiology at Johns Hopkins University in Baltimore, Maryland. The primordial approach targets any underlying structural heart disease and the secondary approach is to prevent development and maturation of the disease. The following table delineates the strategies used today to treat AF and how they might evolve over the next 10 years.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/10936\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/10936\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/10936\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2006 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/6\/5\/7.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlzl2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlzl2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzlzl2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}