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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\u003EThis article reviews the current treatment approaches and emerging therapies for atrial fibrillation.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EThere are an estimated 2.2 million people in the United States with atrial fibrillation (AF). Approximately 70% of these individuals are aged between 65 and 85 years. The prevalence of AF is 2.3% in people aged \u0026gt;40 years and 5.9% in those aged \u0026gt;65 years [Feinberg MW et al. \u003Cem\u003EArch Intern Med\u003C\/em\u003E 1995]. AF in patients with heart failure (HF) increases from \u0026lt;10% in those who are classified as New York Heart Association (NYHA) functional class I to approximately 50% in NYHA functional class IV patients [Maisel WH et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E 2003].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ECatheter ablation is a successful procedure for the treatment of AF in appropriately selected patients, more for paroxysmal compared with persistent\/permanent AF. Single and multiple procedure success rates are between 60% to 75% and 70% to 85%, respectively. The current approach to performing ablation is to create continuous lesions that encircle the ipsilateral pulmonary vein, placed with irrigated radiofrequency energy to prevent microreentry and, hence, atrial arrhythmias. Raul Mitrani, MD, University of Miami, Miami, Florida, USA, reviewed the current treatment approaches and emerging therapies for AF.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EIn their 2011 focused update for maintenance of sinus rhythm, the American College of Cardiology\/American Heart Association\/Heart Rhythm Society (ACC\/AHA\/HRS) modified or added new recommendations concerning the use of catheter ablation for the maintenance of sinus rhythm [Wann LS et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EModified recommendations\u003C\/h2\u003E\n         \u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-5\u0022\u003ECatheter ablation, performed in experienced centers (\u0026gt;50 AF catheter ablations\/year) is useful in maintaining sinus rhythm in selected patients with significantly symptomatic, paroxysmal AF who have failed treatment with an antiarrhythmic drug and have normal or mildly dilated left atria, normal or mildly reduced left ventricular (LV) function, and no severe pulmonary disease (Class I; Level of Evidence [LOE]: A)\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-6\u0022\u003EIn patients with AF without structural or coronary heart disease, initiation of propafenone or flecainide can be beneficial on an outpatient basis in patients with paroxysmal AF who are in sinus rhythm at the time of drug initiation. (Class IIa; LOE: B)\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ENew recommendations\u003C\/h2\u003E\n         \u003Cul class=\u0022list-unord \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-7\u0022\u003ECatheter ablation is reasonable to treat symptomatic persistent AF. (Class IIa; LOE: A)\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n               \u003Cp id=\u0022p-8\u0022\u003ECatheter ablation may be reasonable to treat symptomatic paroxysmal AF in patients with significant left atrial dilatation or with significant LV dysfunction. (Class IIb; LOE: A)\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EDr. Mitrani reviewed data from several ablation studies, some of which were cited by the ACC\/AHA\/HRS as contributing to the revised recommendations. Wilber et al. reported results from a prospective, multicenter study that compared catheter ablation with antiarrhythmic drug therapy (ADT) in 167 patients with symptomatic paroxysmal AF who did not respond to at least one antiarrhythmic drug and who experienced at least 3 AF episodes within 6 months before randomization. At 9 months, 66% of patients in the catheter ablation group remained free from protocol-defined treatment failure (documented symptomatic paroxysmal AF during the effectiveness evaluation period; repeat ablation after Day 80 of the initial ablation, absence of entrance block confirmed in all pulmonary veins at the end of the ablation procedure, or changes in specified drug regimen postblanking were also considered treatment failures as were adverse events requiring discontinuation of the assigned drug in the ADT group) compared with 16% of patients who were treated with ADT (HR, 0.30; 95% CI, 0.19 to 0.47; p\u0026lt;0.001). Major 30-day treatment-related adverse events occurred in 5 of 57 patients (8.8%) who were treated with ADT and 5 of 103 patients (4.9%) who were treated with catheter ablation. Mean quality of life scores improved significantly (p\u0026lt;0.001) in patients who were treated by catheter ablation compared with ADT at 3 months; improvement was maintained during the course of the study [Wilber DJ et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2010]. Support for ablation also comes from a meta-analysis of 35 studies, in which radiofrequency ablation was more effective at preventing AF compared with ADT in either paroxysmal or persistent AF [Parkash R et al. \u003Cem\u003EJ Cardiovasc Electrophysiol\u003C\/em\u003E 2011]. In another study, catheter ablation of AF was effective in approximately 80% of patients after 1.3 procedures per patient, with approximately 70% of patients not requiring further ADT during intermediate follow-up [Cappato R et al. Circ \u003Cem\u003EArrhythm Eledctrophysiol\u003C\/em\u003E 2010].\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EFinally, Ouyang and colleagues showed that long-term circumferential pulmonary isolation results in stable sinus rhythm in the majority of appropriately selected patients with paroxysmal AF and normal LV function, and a low incidence of recurrent AF was noted after 5 years of follow-up [Ouyang F et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2010]. The long-term recurrence rate for AF after an initially successful ablation is secondary to electrical reconnection from the pulmonary veins; hence, a repeat ablation may restore sinus rhythm.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EThe existing focal catheter technology has been adapted to isolate pulmonary veins and ablate atrial tissue. For focal catheters that are not specifically designed for pulmonary vein isolation, there are still challenges: good lesions require transmurality; cardiac contractions make maintaining position difficult; patient anatomy is variable; atrial tissue depth is variable; catheter force varies with position in the heart; and successful procedures require contiguous lesions.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ENewer approaches, such as cryoablation, use a balloon and freezing. The Arctic Font\u003Csup\u003E\u00ae\u003C\/sup\u003E Cardiac CyroAblation Catheter System creates a circumferential, transmural lesion by removing heat from the tissue, leading with a wave of hypothermia, with the coldest temperatures contained within the ablation zone around the balloon, which ablates at the point of tissue contact.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EThe STOP AF (clarify randomized, nonrandomized) (Sustained Treatment of Paroxysmal Atrial Fibrillation) trial compared ablation with the Arctic Front system and ADT in 245 patients with paroxysmal AF. To be eligible, patients were required to have experienced at least 2 episodes of AF within 2 months, as documented by ECG, or to have failed at least one antiarrhythmic drug. The study population was relatively young (mean age 56 years), with a mean CHADS\u003Csub\u003E2\u003C\/sub\u003E score of 0.6. Patients were followed for 12 months, with 69.9% of patients who were treated with cryoablation achieving the primary endpoint of freedom from AF versus 7.3% in the AF drug group (OR, 29.5; CI, 12.0 to 72.2; p\u0026lt;0.001; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Seventy-nine percent of patients who were treated with ADT demonstrated chronic treatment failure and crossed over to the cryoablation procedure. In addition, 98.2% of cryoablation-treated patients had acute procedural success; 62.2% of patients were treatment successes without any ADT at 12 months, and 60.1% was considered successful after a single procedure [Packer D. ACC 2010]. Cryoablation patients experienced clinically significant improvements in both the physical and mental components of quality of life areas, measured by the SF-36 questionnaire. In the cryoablation group, there were no atrioesophageal fistulas, 1 patient suffered a stroke that was related to the procedure\/device, 3.1% of patients had a pulmonary vein stenosis, and 11.2% (including drug crossovers) had phrenic nerve palsy.\u003C\/p\u003E\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\/11\/9\/28\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Effectiveness Results: Freedom from AF After 90 Days.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-594568578\u0022 data-figure-caption=\u0022Effectiveness Results: Freedom from AF After 90 Days.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/28\/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\/11\/9\/28\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\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\/11\/9\/28\/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\/12574\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\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EEffectiveness Results: Freedom from AF After 90 Days.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from R. Mitrani, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EThe final technique that was discussed was visually-guided laser, which may achieve success rates that are similar to or superior to radiofrequency ablation and cryoablation. Successful long-term pulmonary vein isolation is reported to be as high as 90%, which is superior to the current technology. After a single procedure, 60% of patients are free from AF.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 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\/11\/9\/28.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?nzn05p\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?nzn05p\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}