Non Fluoroscopic APpROach iN atriaL Fibrillation Ablation procEdureS

Atrial fibrillation (AF) is the most common sustained adult tachyarrhythmia found in clinical practice. The prevalence of this arrhythmia in the general population varies from 2 to 4% and increases significantly in elderly patients and in carriers of diseases such as arterial hypertension, heart failure, coronary and valvular disease, obesity, diabetes mellitus and chronic kidney disease. In addition to being a marker of underlying heart or vascular disease, FA in itself is accompanied by an increased incidence of ischemic stroke, heart failure and dementia. The mechanisms underlying this arrhythmia are still debated, but seem to involve electrical and structural alterations of the atrium that constitute a morpho-functional substrate that facilitate its development.

Traditionally, five types of atrial fibrillation are distinguished, based on presentation, duration and term:

1. Newly diagnosed AF: first finding of AF, regardless of the duration, presence and severity of symptoms;
2. Paroxysmal AF: AF that resolves within seven days (spontaneously or through cardioversion);
3. Persistent AF: AF that lasts more than seven days or is cardioverted after seven days;
4. Long lasting AF: AF that lasts more than a year continuously, when a rhythm control strategy has been adopted.
5. Permanent AF: AF accepted by the patient (and by the attending physician) for which no further attempt to control the rhythm is undertaken.

Treatment include heart rate and / or rhythm control strategies, prevention of cerebral thromboembolism and reduction / elimination of symptoms, as well as control of major cardiovascular risk factors. The decision about the implementation of therapeutic strategies aimed at restoring and maintaining sinus rhythm must be shared between doctor and patient, weighing on the one hand the effect on quality of life and symptoms, and on the other the risk of toxic effects of drugs. used. When AF has been on for less than a year, an early rhythm control strategy has been shown to reduce the composite outcome of cardiovascular death, stroke, hospitalization for heart failure or acute coronary syndrome in the EAST-AFNET 4 clinical trial.

Trans catheter ablation is a well-established treatment for the reduction of AF relapses and is proposed in cases of paroxysmal and persistent AF. It is a procedure that consists in the antral circumferential disconnection of the pulmonary veins by radiofrequency, laser or cryoblation. It is a safe and effective technique for maintaining sinus rhythm and for improving symptoms. When antiarrhythmic drugs fail in rhythm control, the current ESC 2020 Guidelines place trans-catheter ablation in class I for paroxysmal and persistent AF with or without major risk factors for recurrence, while as a first therapeutic approach it is in class IIa for paroxysmal AF and IIb for persistent AF without major risk factors for relapse.