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Catheter Ablation of Atrial Fibrillation: identifying predictors of ablation success to guide a patient-tailored treatment

Book - Dissertation

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its prevalence is expected to rise. After two decades of controversy over the best treatment strategy for AF patients (rate vs rhythm control), the balance is slightly tilting back towards the latter, at least in patients early after diagnosis (i.e. ≤ 1 year) and those with heart failure (HF). Moreover, clinical trials have demonstrated the superiority of early ablation compared to antiarrhythmic drugs. The core of this doctoral research was: 1) to identify which patients might not benefit from the standard pulmonary vein isolation (PVI) treatment and explore alternatives. 2) to investigate which HF patients might benefit most from the ablation strategy. In the quest to predict PVI success, the study delved into structural and functional properties of the left atrium. The MASH AF II Study revealed a critical insight: low voltage zones (LVZ) in the atrium are tied to AF recurrence. But this relationship isn’t one-size-fits-all. Its impact varies: paroxysmal AF patients are different from those with persistent AF, and gender disparities exist. Women, despite having more atrial remodeling, showed a similar AF recurrence-free survival rate as men. Interestingly, in assessing treatment options for patients with significant LVZs, the MiLine Study found that adding an anterior mitral line to standard treatment improved outcomes for patients with anterior scar. The INDUCE AF Study offered another perspective. It proposed that the cycle length during AF, specifically in paroxysmal AF patients, can be a solid predictor of PVI success. In essence, how the atrium behaves during AF can offer a clue about post-ablation outcomes. For HF patients, predicting recovery post-ablation became a key challenge. The ANTWERP score was conceived for this, utilizing predictors like etiology, AF pattern, atrial volume, and QRS duration. This score, upon external validation in the ANTWOORD-2 study, proved to be a robust tool, predicting left ventricular ejection fraction (LVEF) improvement after ablation. Patients with a higher score saw better heart function recovery, fewer hospitalizations, and reduced mortality. In sum, this research underscores the importance of a tailored approach to treating AF. Recognizing baseline characteristics and specific atrial properties can be pivotal in predicting how a patient responds to ablation. This individualized approach, coupled with the tools and insights from the study, not only can enhance patient outcomes but also serve as a foundation for standardizing and refining future research in AF treatment.
Number of pages: 134
Publication year:2023
Keywords:Doctoral thesis