Approaches to non-pharmacological treatment of persistent atrial fibrillation: what are the future prospects?

The main approaches to non-drug therapy of persistent atrial fibrillation were considered. The role of different treatment strategies was assessed: surgical, endoscopic, catheter ablation and cryoballon ablation of target anatomical substrates. Catheter isolation of the pulmonary veins is the most effective strategy for treatment of patients with paroxysmal atrial fibrillation; however, the success of this technique for persistent atrial fibrillation treatment remains low despite the wide range of catheter techniques used. The posterior wall of the left atrium makes a significant contribution to the development of this process, which confirms the high efficiency of its surgical isolation, even in patients with long-term persistent atrial fibrillation. Today, there is growing evidence in favor of isolation of the pulmonary veins in combination with isolation of the posterior wall of the left atrium using a cryoballoon. The data of clinical studies comparing the safety and efficacy of this approach in comparison with other invasive methods in the long-term period are presented. The technical reproducibility of the technique, high immediate and long-term success of the procedure with respect to maintaining sinus rhythm were noted.

1. Elliott A.D., Middeldorp M.E., Van Gelder I.C., Albert C.M., Sanders P. Epidemiology and modifiable risk factors for atrial fibrillation. Nat Rev Cardiol. 2023 Jun;20(6):404-417. doi: 10.1038/s41569-022-00820-8.

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

3. Gutierrez C., Blanchard D.G. Diagnosis and Treatment of Atrial Fibrillation. Am Fam Physician. 2016 Sep 15;94(6):442-52.

4. Sapelnikov O.V., Kulikov A.A., Grishin I.R., Cherkashin D.I. et al. Catheteral cryoablation in treatment of atrial fibrillation. Opportunities and prospects. Russian Cardiology Bulletin 3 т.XII, 2017.

5. Mohanty S., La Fazia V.M., Torlapati P.G., Gianni C., Macdonald B., Mayedo A., Della Rocca D.G., Bassiouny M., Gallinghouse G.J., Burkhardt J.D., Horton R., Al-Ahmad A., Di Biase L., Natale A. Distribution of triggers in the left atrial posterior wall in AF patients undergoing catheter ablation, European Heart Journal, Volume 44, Issue Supplement_2, November 2023, ehad655.374. doi:10.1093/eurheartj/ehad655.374

6. Yokokawa M., Chugh A., Latchamsetty R., Ghanbari H., Crawford T., Jongnarangsin K., Cunnane R., Saeed M., Sunkara B., Tezcan M., Bogun F., Pelosi F., Jr Morady F., Oral H. Cryoballoon antral pulmonary vein isolation vs contact force-sensing radiofrequency catheter ablation for pulmonary vein and posterior left atrial isolation in patients with persistent atrial fibrillation. Heart Rhythm. 2018;15(12):1835-1841. doi:10.1016/j.hrthm.2018.06.047

7. Roberts J.D., Gerstenfeld E.P. Concomitant Isolation of the Pulmonary Veins and Posterior Wall Using a Box Lesion Set in a Patient with Persistent Atrial Fibrillation and Variant Pulmonary Venous Anatomy. Card Electrophysiol Clin. 2016 Mar;8(1):145- 9. doi: 10.1016/j.ccep.2015.10.015.

8. Ho S.Y., Cabrera J.A., Sanchez-Quintana D. Left atrial anatomy revisited. Circ Arrhythm Electrophysiol. 2012;5(1):220-228. doi:10.1161/CIRCEP.111.962720.

9. Clarke J.D., Piccini J.P., Friedman D.J. The role of posterior wall isolation in catheter ablation of persistent atrial fibrillation. J Cardiovasc Electrophysiol. 2021;32(9):2567-2576. doi:10.1111/jce.15164

10. Cox J.L. The role of surgical intervention in the management of atrial fibrillation. Tex Heart Inst J. 2004;31(3):257-265.

11. Vos L.M., Kotecha D., Geuzebroek G.S.C., Hofman F. N., van Boven W. J. P., Kelder J., de Mol B. A. J. M., van Putte B.P. Totally thoracoscopic ablation for atrial fibrillation: a systematic safety analysis. Europace. 2018;20(11):1790–1797. doi:10.1093/europace/eux385

12. Kwon H.J., Jeong D.S., Park S.J., Park K.M., Kim J.S., On Y.K. Long-term outcome of totally thoracoscopic surgical ablation in atrial fibrillation: A single-center experience. Int J Cardiol Heart Vasc. 2021 Aug 25;36:100861. doi: 10.1016/j.ijcha.2021.100861.

13. Compier M.G., Braun J., Tjon A., Zeppenfeld K., Klautz R.J.M., Schalij M.J., Trines S.A. utcome of stand-alone thoracoscopic epicardial left atrial posterior box isolation with bipolar radiofrequency energy for longstanding persistent atrial fibrillation. Neth Heart J. 2016;24(2):143-151. doi:10.1007/s12471-015-0785-3

14. Pojar M., Vojacek J., Haman L., Parizek P., Harrer J. T Thoracoscopic radiofrequency ablation for lone atrial fibrillation: box-lesion technique. J Card Surg. 2014;29(5):757-762. doi:10.1111/jocs.12409.

15. Neefs J., Wesselink R., van den Berg N.W.E., de Jong J.S.S.G., Piersma F.R., van Boven W.P., Driessen, A.H.G., de Groot J.R. Thoracoscopic surgical atrial fibrillation ablation in patients with an extremely enlarged left atrium. J Interv Card Electrophysiol. 2022;64(2):469-478. doi:10.1007/s10840-021-01056-1.

16. Ревишвили А.Ш., Стребкова Е.Д., Артюхина Е.А., Малышенко Е.С., Новиков М.А., Кадырова М. Эффективность торакоскопического лечения непароксизмальных форм фибрилляции предсердий. Вестник аритмологии. 2023;30(3):23-31. doi:10.35336/VA-1160

17. Probst J., Jidéus L., Blomström P., Zemgulis V., Wassberg E., Lönnerholm, S., Malmborg H., Blomström Lundqvist C. Thoracoscopic epicardial left atrial ablation in symptomatic patients with atrial fibrillation. Europace. 2016;18(10):1538-1544. doi:10.1093/europace/euv438

18. Proietti R., Santangeli P., Di Biase L., Joza J., Bernier M.L., Wang Y., Sagone A., Viecca M., Essebag V., Natale A. Comparative effectiveness of wide antral versus ostial pulmonary vein isolation: a systematic review and meta-analysis. Circ Arrhythm Electrophysiol. 2014;7(1):39-45. doi:10.1161/CIRCEP.113.000922

19. Verma A., Jiang C.Y., Betts T.R., Chen J., Deisenhofer I., Mantovan R., Macle L., Morillo C.A., Haverkamp W., Weerasooriya R., Albenque J.P., 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.

20. Sabatino F., Oriente D., Fortunato F., Cascino A., Ferrara G., Sgarito G., Conti S. Extensive Posterior Wall Isolation on Top of Pulmonary Vein Isolation Guided by Ablation Index in Persistent Atrial Fibrillation Ablation. Life (Basel). 2023 Mar 11;13(3):761. doi: 10.3390/life13030761. PMID: 36983916; PMCID: PMC10052169.

21. Aryana A., Pujara D. K., Allen S. L., Baker J. H., Espinosa M. A., Buch E. F., Srivatsa U., Ellis E., Makati K., Kowalski M., Lee S., Tadros, T. Baykaner, T., AlAhmad A., d'Avila A., Di Biase L., Okishige K., Natale A. Left atrial posterior wall isolation in conjunction with pulmonary vein isolation using cryoballoon for treatment of persistent atrial fibrillation (PIVoTAL): study rationale and design [published online ahead of print, 2020 Oct 3]. J Interv Card Electrophysiol. 2020;10.1007/s10840-020-00885-w.

22. Fortuni F., Casula M., Sanzo A., Angelini F., Cornara S., Somaschini A., Mugnai G., Rordorf R., De Ferrari G.M. Meta-Analysis Comparing Cryoballoon Versus Radiofrequency as First Ablation Procedure for Atrial Fibrillation. Am J Cardiol. 2020 Apr 15;125(8):1170-1179. doi: 10.1016/j.amjcard.2020.01.016.

23. Knight B.P., Novak P.G., Sangrigoli R., Champagne J., Dubuc M., Adler S. W., Svinarich J. T., Essebag V., Hokanson R., Kueffer F., Jain S. K., John R. M., Mansour M., STOP AF PAS Investigators. LongTerm Outcomes After Ablation for Paroxysmal Atrial Fibrillation Using the Second-Generation Cryoballoon: Final Results From STOP AF Post-Approval Study. JACC Clin Electrophysiol. 2019 Mar;5(3):306-314. doi: 10.1016/j.jacep.2018.11.006.

24. Murray M.I., Arnold A., Younis M., Varghese S., Zeiher A.M. Cryoballoon versus radiofrequency ablation for paroxysmal atrial fibrillation: a metaanalysis of randomized controlled trials. Clin Res Cardiol. 2018 Aug;107(8):658-669. doi: 10.1007/s00392-018-1232-4.

25. Andrade J.G., Wazni O.M., Kuniss M., Hawkins N.M., Deyell M.W., Chierchia G.B., Nissen S., Verma A., Wells G.A., Turgeon R.D. Cryoballoon Ablation as Initial Treatment for Atrial Fibrillation: JACC State-of-the-Art Review. J Am Coll Cardiol. 2021 Aug 31;78(9):914-930. doi: 10.1016/j.jacc.2021.06.038. PMID: 34446164.

26. Kuck K.H., Brugada J., Fürnkranz A., Metzner A., Ouyang F., Chun K.R., Elvan A., Arentz T., Bestehorn K., Pocock S. J., Albenque J. P., Tondo C., FIRE AND ICE Investigators. Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation. N Engl J Med. 2016;374(23):2235-2245. doi:10.1056/NEJMoa1602014

27. Kuck K.H., Brugada J., Schlüter M., Braegelmann K.M., Kueffer F.J., Chun K.R.J., Albenque J.P., Tondo C., Calkin H., FIRE AND ICE Trial Investigators. The FIRE AND ICE Trial: What We Know, What We Can Still Learn, and What We Need to Address in the Future. J Am Heart Assoc. 2018;7(24):e010777. doi:10.1161/JAHA.118.010777

28. Okumura Y., Watanabe I., Iso K., Takahashi K., Nagashima K., Sonoda K., Mano H., Yamaguchi N., Kogawa R., Watanabe R., Arai M., Ohkubo K., Kurokawa S., Nakai T., Hirayama A. Mechanistic Insights Into Durable Pulmonary Vein Isolation Achieved by Second-Generation Cryoballoon Ablation. J Atr Fibrillation. 2017;9(6):1538. Published 2017 Apr 30. doi:10.4022/jafib.1538.

29. Sarairah S.Y., Woodbury B., Methachittiphan N., Tregoning D.M., Sridhar A.R., Akoum N. “Esophageal Thermal Injury Following Cryoballoon Ablation for Atrial Fibrillation. JACC Clin Electrophysiol. 2020;6(3):262-268. doi:10.1016/j.jacep.2019.10.014.

30. Kuniss M., Greiß H., Pajitnev D., Akkaya E., Deubner N., Hain A., Bodammer L., Berkowitsch A., Chierchia G.B., Hamm C.W., Neumann T. Cryoballoon ablation of persistent atrial fibrillation: feasibility and safety of left atrial roof ablation with generation of conduction block in addition to antral pulmonary vein isolation. Europace. 2017 Jul 1;19(7):1109-1115. doi: 10.1093/europace/euw146.

31. Aryana A., Baker J.H., Espinosa Ginic M.A., Pujara D.K., Bowers M.R., O'Neill P.G., Ellenbogen K.A., Di Biase L., d'Avila A., Natale A. Posterior wall isolation using the cryoballoon in conjunction with pulmonary vein ablation is superior to pulmonary vein isolation alone in patients with persistent atrial fibrillation: A multicenter experience. Heart Rhythm. 2018;15(8):1121-1129. doi:10.1016/j.hrthm.2018.05.014.

32. Nanbu T., Yotsukura A., Suzuki G., Ishidoya Y., Sano F., Yoshida I., Sakurai M. Important factors in left atrial posterior wall isolation using 28-mm cryoballoon ablation for persistent atrial Fibrillation-Block line or isolation area? J Cardiovasc Electrophysiol. 2020 Jan;31(1):119-127. doi: 10.1111/jce.14281

33. Ahn J., Shin D.G., Han S.J., Lim H.E. Does isolation of the left atrial posterior wall using cryoballoon ablation improve clinical outcomes in patients with persistent atrial fibrillation? A prospective randomized controlled trial. Europace. 2022 Jul 21;24(7):1093-1101. doi: 10.1093/europace/euac005.