Evolution of non-pharmacological curative therapy for atrial fibrillation. Where do we stand today?

The present review aims at giving a comprehensive synthesis regarding not only the epidemiological aspects but also the evolution, over the last decades, of the curative surgical and catheter-based ablative treatments for atrial fibrillation (AF), with particular emphasis on the experience of Milan working group which has always been committed to the on-going and fascinating therapeutic challenges inherent in this type of cardiac arrhythmia. After discussing the surgical treatment of AF we report the rationale basis of current pulmonary vein (PV) ablation techniques. In particular, we report on circumferential PV ablation, an intellectually appealing strategy, aimed at creation of RF lesions around each PV ostia using a non-fluoroscopic electro-geometric mapping system to reconstruct the anatomy of venous-atrial junction, allowing to tailor number and size of lesions to the complex morphology of the PV-LA junction in each patient. This purely anatomic approach not only disconnects PVs (as demonstrated by elimination of PV ostial potentials and absence of discrete electrical activity inside the lesion during pacing outside the ablation line), but also, like surgery, reduces the "electrically active" atrial tissue, involving substantial parts of the posterior LA wall, with a profound atrial electroanatomic remodeling, as expressed by voltage abatement (<0.1 mV) inside and around the encircled areas.