Ablation of Driver Domains During Persistent Atrial Fibrillation
A Call for More Understanding
In this issue of Circulation, readers will find a fascinating study presented by Dr Haissaguerre and several members of a promising and newly created institute for cardiovascular research located in Bordeaux, France, the LIRYC (L’institut de Rythmologie et de Modélisation Cardiaque [The Institute for Arrhythmia and Computer Modeling Research]).1 This is yet another pioneering contribution from the Bordeaux group that, if confirmed, may improve the management of patients with persistent atrial fibrillation (AF).
Article see p 530
AF is commonly classified as paroxysmal (PAF) or persistent (PsAF), depending on the duration of the arrhythmic episodes, <7 or >7 days.2 PsAF may also be subclassified as long-standing persistent (LPsAF) when fibrillation has been continuous for >1 year.2 In the late 1990s, Dr Haissaguerre and team’s seminal work indicated that, in patients with PAF, a catheter ablation procedure may be targeted at discrete pulmonary vein (PV) electric foci and that PV electric isolation from the remainder of the atrial muscle may prevent AF reinitiation.3,4 Although the exact nature of PV foci has never been fully elucidated, this procedure proved successful in terminating AF and in preventing its recurrence.5,6 Later, a consensus emerged to propose PV isolation to patients with PAF, alone or in combination with an antiarrhythmic drug therapy.2 Thereafter, many suggested that this procedure may also improve the outcome of patients with PsAF,7–9 with, however, the need for adjustments in the ablation strategy.8–11 Despite these efforts, the success rate of catheter ablation for patients with PsAF, let alone LPsAF, has remained substantially lower than that of PAF ablation.5,6 A nearly unanimous view is that ablation works well for PAF but that the procedure is more tedious and the outcome less predictable …