Atrial fibrillation: nonpharmacologic approaches

Various nonpharmacologic interventions are available for patients with atrial fibrillation (AF) who are refractory to standard drug therapy. Atrioventricular junctional ablation and permanent pacing is a very effective therapy for patients with AF and a poorly controlled ventricular response. The surgical MAZE procedure has been performed on small numbers of patients but is remarkably successful in restoring and maintaining sinus rhythm. The role of permanent pacing as treatment for paroxysmal AF is undergoing evaluation and dual-site atrial pacing appears particularly promising in reducing the number of episodes of paroxysmal AF. Certainly the most exciting frontier in the treatment of AF is radiofrequency catheter ablation procedures. Our understanding of the mechanisms of paroxysmal AF and chronic AF has expanded enormously in the past 5 years. Radiofrequency lesions in pulmonary veins using standard technology will cure many cases of paroxysmal AF. However, catheter systems under development offer a great promise of treating most paroxysmal and chronic AF within the next few years. These developments will revolutionize our approach to this ever more prevalent clinical problem.