Catheter and surgical ablation strategies in atrial fibrillation: what have we learned?

PURPOSE OF REVIEW: Atrial fibrillation can be eliminated by catheter or surgical ablation, using significantly different approaches and end points. The former has mostly been guided by electrophysiologic recordings, whereas the latter uses direct anatomic visualization. RECENT FINDINGS: Rather than focusing only on ablating triggers of atrial fibrillation, such as pulmonary vein potentials, catheter ablation has evolved toward modification of the left atrial tissue substrate. Correlation of ablation sites with vagal denervation appears to enhance the success of ablation. Integration and eventually registration of spiral CT or MRI images with direct electrophysiologic intracardiac signals will lead to superimposition of true anatomic-electrophysiologic sites, providing enhanced accuracy during mapping. As for surgery, combining endocardial surgical ablation at the time of valvular heart surgery in patients who also have atrial fibrillation has become an integral aspect of surgery. The development of minimally invasive surgery has led to epicardial ablation of atrial fibrillation and even removal of the left atrial appendage, without even entering the heart. SUMMARY: The favorable benefit-to-risk profile, associated with improved outcomes, should eventually lead to reduced morbidity and mortality associated with atrial fibrillation.