Atrial fibrillation ablation strategies and technologies: past, present, and future.

Catheter ablation is an established treatment option for atrial fibrillation (AF), and pulmonary vein isolation (PVI) has become the gold standard in AF ablation. AF recurrence after PVI remains an important clinical problem. Recovery of conduction from the pulmonary veins (PVs) is considered the dominant mechanism for AF recurrence in paroxysmal AF. However, the underlying mechanism of AF recurrence after PVI is more complex in patients with persistent and longstanding persistent AF. Different ablation technologies and energy sources have been developed aimed at improving lesion quality and durability with an acceptable safety profile. Novel technologies are under evaluation which have a great potential to produce permanent PVI after a single ablation procedure. However, clinical value of these novel devices needs to be tested in adequately powered randomized controlled trials. In this article, we review the history of catheter ablation for AF and discuss the present and future ablation technologies.

Trends in warfarin use and its associations with thromboembolic and bleeding rates in a population with atrial fibrillation between 1996 and 2011.

AIM: Warfarin is a cornerstone for the prevention of thromboembolism in atrial fibrillation (AF), and several efforts have been taken to increase its usage and safety, including risk stratification schemes. Our aim was to investigate the temporal trends in initiation of warfarin and its effects on incidence of bleeding and thromboembolism in patients with new-onset atrial fibrillation 1996-2011. METHODS: All patients with a first-time diagnosis of non-valvular atrial fibrillation were identified from nationwide administrative registries. Trends were determined by linear regression. RESULTS: In total 153,682 patients were included. Initiation of warfarin increased from 14% to 41% (p<0.0001). Events of thromboembolism decreased from 3.9% to 2.6% annually (p<0.0001). The greatest decline in thromboembolic events was observed for patients with a CHA2DS2VASc score >1, where the annual decline was -0.12% (95%CI: -0.161; -0.084)) for those treated with warfarin and -0.073% (95%CI: -0.116;-0.030)) for those not treated with warfarin. Bleeding increased from 3.3% to 3.9% (p = 0.043). For those with a CHA2DS2VASc score >1 annual bleeding rates increased by 0.095% (95%CI: -0.025; -0.165) in warfarin treated and by 0.056% (95%CI: -0.013; -0.100) in patients not treated with warfarin. CONCLUSION: Warfarin use increased by nearly a 3-fold between 1996 and 2011. During the same period, thromboembolic events declined by a third and bleeding increased by a fifth, suggesting a beneficial effect associated with higher warfarin use. Notably, a small decline in thromboembolic events and increase in bleeding events was observed for the untreated population, suggesting a changing risk profile of AF patients.

In Carthage ruins: the illness of Sir Winston Churchill at Carthage, December 1943.

This paper reviews Churchill's illness in Carthage in December 1943. It was characterised by fever that lasted 6 days, left lower lobe pneumonia and two episodes of atrial fibrillation. He was managed in a private villa by Lord Moran, his personal physician, with the assistance of two nurses and the expert advice of colleagues. Sulphadiazine and digitalis leaf were prescribed and Churchill recovered. It is remarkable that, despite the severity of his illness, he continued to direct the affairs of State from his bed.

[Why does our heart fibrillate?- or what goats can teach us]. / Warum flimmert unser Herz? -order was der Mensch von der Ziege lernen kann.

Our present knowledge about cardiac electrophysiology is based on numerous experiments and discoveries going back to the Greek antique and ancient Egypt. Exploration of cardiac anatomy was followed by the description of circulation and cardiac physiology in the 17th century. In the early 20th century cardiac electrophysiology became the new field of interest and was studied with the help of numerous animal experiments (squid, rays, dogs, goats, mice and other species). We ought to be grateful for the knowledge and possibilities in modern medicine that were made possible by the great number of researchers, patients and animals that contributed to this.

Nos connaissances actuelles en électrophysiologie cardiaque sont basées sur de nombresuses expériences et décovertes remontant jusqu'à la Grèce antique et l'ancienne egypte. L'exploration de l'anatomie cardiaque a été suivie au 17ème siècle par la description de la circulation et de la physiologie cardiaque. Au début du 20ème siècle l'électrophysiologie cardiaque est devenue un nouveau centre d'intérêt et a été extensivement explorée dans plusieurs espèces animales. Noua devrions être reconnaissants au grand nombre de chercheurs, patients et animaux qui ont contribué à l'acquisition des connaissances et les possibilités offertes par la médecine moderne.

Vascular and heart diseases in the incumbent presidents and vice presidents of the United States of america: a medical-historical perspective.

Vascular diseases have been the major cause of death and disability in presidents and vice presidents of the United States. Untreated hypertension and cigarette smoking have contributed greatly to this increased morbidity and mortality risk, which has impacted on historical events, especially in the 20th century. In this article, the medical histories of those incumbent Presidents and Vice Presidents who suffered from coronary artery and cerebrovascular diseases will be reviewed. A discussion of how atrial fibrillation has affected the Presidents is also included.

Surgical ablation for atrial fibrillation.

This paper reviews the history of surgical procedures developed for eradication of atrial fibrillation (AF) during cardiac surgery for structural heart disease, and in patients with AF without other indication for cardiac surgery. Current evidence indicates that, despite their proven efficacy, the Cox-Maze procedure and its modifications require cardiopulmonary bypass and cannot be easily justified in the case of AF without other indication for cardiac surgery. In patients undergoing cardiac surgery for mitral valve disease, concomitant ablation techniques using modifications of the Maze and alternative energy sources appear to be safe and effective in treating AF, especially in non-rheumatic disease. Minimally invasive epicardial ablation has been recently developed and can be performed on a beating heart through small access incision ports. Various techniques combining pulmonary vein isolation, ganglionated plexi ablation, and left atrial lines have been tried. Initial results are promising but further clinical experience is required to establish ideal lesion sets, appropriate energy sources, and the benefit-risk ratio of such an approach in patients without other indication for cardiac surgery. The role of surgical ablation in the current management of AF is under investigation.