Non-Invasive Diagnosis and Hybrid Treatment of Atrial Fibrillation

Atrial fibrillation (AF) is the most common tachyarrhythmia, and its incidence in the general population is 1-2% among all cardiac arrhythmias. The search for optimal, safe, minimally invasive methods of diagnosis and treatment of isolated nonparoxymal forms of AF is a global problem of modern arrhythmology.

Aim: to provide a systematic literature review on the possibilities of surface mapping of persistent forms of AF and to consider modern approaches to the treatment of resistant forms of AF.

Materials and methods: the review of the medical literature published in the period from 2013 to 2023 was conducted using data from the information and analytical systems MEDLINE, Scopus, Clinicaltrials.gov , Google Scholar and Web of Science. The presented literature review includes 30 studies.

Results: noninvasive surface mapping of the heart allows overcoming a number of limitations of invasive endocardial mapping systems: (1) reducing the frequency of complications; (2) simultaneous biatrial electrophysiological assessment; (3) anatomical features of the localization of an arrhythmogenic focus; (4) the possibility of mapping in one cardiac cycle.

Catheter methods of AF treatment show extremely low efficacy against non-paroxysmal forms of AF, decreasing with each subsequent ablation procedure. For patients with resistant forms of AF, it is rational to consider a two-stage or hybrid treatment approach combining epi- and endocardial ablations. The effectiveness of this treatment method reaches 86,9% in the long-term follow-up period.

The prospect of future treatment of resistant forms of AF is the use of noninvasive stereotactic radioablation, which has shown high efficacy in the treatment of life-threatening ventricular tachyarrhythmias.

Conclusion: the prospect of future treatment of persistent forms of AF should be considered as surface mapping of all chambers of the heart, followed by noninvasive stereotactic radiotherapy, which can ensure minimal risks of complications and achieve efficiency comparable to the classic Cox-Maze procedure.

1. Hindricks G., Potpara T., Dagres N., et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Rus Card J. 2021; 42: 373498 DOI: 10.1093/eurheartj/ehaa945. [In Russ].

2. Lippi G., Sanchis-Gomar F., Cervellin G. Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge. Int J Stroke. 2021;16(2): 217-221. DOI: 10.1177/1747493019897870

3. Benjamin E.J., Muntner P., Alonso A., et al. Heart diseaseand stroke Statistics-2019 update: A report from the American Heart Association. Circulation. 2019;139: 56-528. DOI: 10.1161/CIR.0000000000000659

4. Je H.G., Shuman D.J., Ad N. A systematic review of minimally invasive surgical treatment for atrial fibrillation: a comparison of the Cox-Maze procedure, beating-heart epicardial ablation, and the hybrid procedure on safety and efficacy. Eur J Cardiothorac Surg. 2015;48(4): 531-40. DOI: 10.1093/ejcts/ezu536

5. Haïssaguerre M., Jaȉs P., Shah D.C., et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998:339; 659-666. DOI: 10.1056/NEJM199809033391003

6. Wesselink R., Neefs J., van den Berg N.W.E, et al. Does leftatrial epicardial conduction time reflect atrial fibrosis and the risk of atrial fibrillation recurrence after thoracoscopic ablation? Post hoc analysis of the AFACT trial. BMJ Open. 2022;12(3): 056829. DOI: 10.1136/bmjopen-2021-056829

7. Revishvili A.Sh., Strebkova E.D., Artyukhina Е.А., Malishenko E.S., Novikov M.A., Kadirova M. The effectiveness of thoracoscopic treatment of non-paroxysmal atrial fibrillation. Journal of Arrhythmology. 2023;30(3): 23-31. DOI: 10.35336/VA-1160 [In Russ].

8. Strebkova ED, Revishvili AS, Malishenko ES, ArtyukhinaEA, Popov VA, Novikov M, et al. Long-term outcomes of thoracoscopic ablation for atrial fibrillation. Journal of Arrhythmology DOI: 10.35336/VA-2023-2-08 [In Russ].

9. Revishvili A.S., Fetisova E.A., Kalinin V.V., Kalinin A.V.,Chaikovskaya M.K., Mironovich S.A., et al. Electrophysiological mechanisms underlying termination of atrial fibrillation: insights gained from non-invasive phase mapping. Journal of Arrhythmology 2017; (88): 5-12 [In Russ].

10. Revishvili A.S., Kalinin V.V., Kalinin A.V., et al.. Noninvasive diagnosis and results of interventional treatment of cardiac arrhythmias using the new «Amicard 01K» non-invasive surface mapping system. Annaly aritmologii. 2012; (3): 40-47.

11. Khlynin M.S., Batalov R.E., Kiselev N.V., et al. Development of non-invasive topical diagnostics of cardiac arrhythmias. Siberian Journal of Clinical and Experimental Medicine. 2019;34(2):9-20 DOI: 10.29001/2073-8552-2019-34-2-9-20 [In Russ].

12. Wolf R.K., Schneeberger E.W., Osterday R., et al. Videoassisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg. 2005;130: 797-802. DOI: 10.1016/j.jtcvs.2005.03.041

13. van Laar C., Kelder J., van Putte B.P. The totally thoracoscopic maze procedure for the treatment of atrial fibrillation. Interact Cardiovasc Thorac Surg. 2017;24: 102-111. DOI: 10.1093/icvts/ivw311

14. Revishvili A.S., Vaskovsky V.A., Artyukhina E.A., Taymasova I.A., Golanov A.V, Antipina N.A., Nikolayeva A.A., et al. Stereotactic radioablation in clinical practice for the treatment of a patient with ventricular tachycardia: case report. Journal of Arrhythmology. 2022;29(4):66-72 DOI: 10.35336/VA2022-4-10 [In Russ].

15. Revishvili A.S., Wissner E., Lebedev D.S., Lemes C., DeissS., Metzner A., et al. Validation of the mapping accuracy of a novel non-invasive epicardial and endocardial electrophysiology system. Europace. 2015; 17(8): 1282-8. DOI: 10.1093/europace/euu339.

16. Parreira L., Tsyganov A., Artyukhina E., Vernooy K., Tondo C., Adragao P., et al. Non-invasive three-dimensional electrical activation mapping to predict cardiac resynchronization therapy response: site of latest left ventricular activation relative to pacing site. Europace. 2023;25(4):1458-1466. DOI: 10.1093/europace/euad041

17. Vaskovskiy V.A., Taymasova I.A., Kalinin D.V., AntipinaN.A., Nikolaeva A.A, Smirnov G.Y., Golanov A.V., Potapov A.A., Revishvili A.Sh. Experimental use of stereotactic radiosurgery for non-invasive interventions in arrhythmology. Journal of Arrhythmology. 2021;28(1): 5-13 [In Russ]. DOI: 10.35336/VA-2021-1-5-13

18. Moher D., Altman D.G., Liberati A., Tetzlaff J. PRISMA statement. Epidemiology. 2011;22(1):128; author reply 128. DOI: 10.1097/EDE.0b013e3181fe7825

19. Artyukhina E.A., Yashkov M.V., Revishvili A.Sh. Non-invasive electrophysiological cardiac mapping from development to practice. Patologiya krovoobrashcheniya i kardiokhirurgiya. Circulation Pathology and Cardiac Surgery. 2020;24(4):33-41 DOI: 10.21688/1681-3472-2020-4-33-41 [In Russ].

20. Revishvili A.S., Wissner E., Lebedev D.S., Lemes C., DeissS., Metzner A., et al. Validation of the mapping accuracy of a novel non-invasive epicardial and endocardial electrophysiology system. Europace. 2015; 17(8): 1282-1288. DOI: 10.1093/europace/euu339

21. Knecht S., Sohal M., Deisenhofer .I, Albenque J.P., ArentzT., Neumann T., et al. Multicentre evaluation of non-invasive biatrial mapping for persistent atrial fibrillation ablation: the AFACART study. Europace. 2017; 19(8): 1302-1309. DOI: 10.1093/europace/euw168

22. Revishvili A.S., Kadirova M., Strebkova E.D., MalishenkoE.S., Novikov M.A., Yalova E.V., et al. Left atrial appendage exclusion using a stapler with thoracoscopic ablation of atrial fibrillation. Complex Issues of Cardiovascular Diseases. 2023; 12(1): 58-71 DOI: 10.17802/2306-1278-2023-12-1-58-71 [In Russ].

23. Revishvili A.S., Artyukhina E.A., Strebkova E.D.,Malyshenko E.S., Kadyrova M. Evolution of thoracoscopic treatment of atrial fibrillation: from inception to contemporary approaches. Complex Issues of Cardiovascular Diseases. 2023;12(2):107-121. DOI: 10.17802/2306-1278-2023-12-2107-121 [In Russ].

24. Leksell L. The stereotaxic method and radiosurgery of the brain. Acta Chir Scand. 1951;102:316-9.

25. Sharma A., Wong D., Weidlich G. et al. Noninvasivestereotactic radiosurgery (cyberheart) for creation of ablation lesions in the atrium. Heart Rhythm. 2010; 7: 802-810. DOI: 10.1016/j.hrthm.2010.02.010

26. Lehmann H.I., Graeff C., Simoniello P. et al. Feasibility study on cardiac arrhythmia ablation using high-energy heavy ion beams. Sci Rep. 2016; 6: 38895. DOI: 10.1038/srep38895

27. Loo Jr B.W., Soltys S.G., Wang L. et al. Stereotactic ablative radiotherapy for the treatment of refractory cardiac ventricular arrhythmia. Circ Arrhythm Electrophysiol. 2015; 8: 748750. DOI: 10.1161/CIRCEP.115.002765

28. Cvek JN.R., Knybel L. et al. Cardiac radiosurgery formalignant ventricular tachycardia. Cureus. 2014;6(7): e190. DOI: 10.7759/cureus.190

29. Van der Ree M.H., Dieleman EM.T., Visser J., PlankenR.N., Boekholdt S.M., de Bruin-Bon RH.A., et al. Non-invasive stereotactic arrhythmia radiotherapy for ventricular tachycardia: results of the prospective STARNL-1 trial. Europace. 2023;25(3):1015-1024. DOI: 10.1093/europace/euad020

30. Di Monaco A., Gregucci F., Bonaparte I., Troisi F., Surgo A.,Di Molfetta D., et al. Paroxysmal Atrial Fibrillation in Elderly: Worldwide Preliminary Data of LINAC-Based Stereotactic Arrhythmia Radioablation Prospective Phase II Trial. Front Cardiovasc Med. 2022;9:832446. DOI: 10.3389/fcvm.2022.832446