Interventional techniques in the management of persistent atrial fibrillation

Abstract

Atrial fibrillation (AF) is a common cardiac rhythm problem experienced by patients and comprises an increasing demand on healthcare systems. AF is characterised by advanced neurohormonal remodelling in the atria resulting in dilation and variable degree of atrial fibrosis that can be measured by imaging techniques with difficulty in developing methods of identifying and quantifying left atrial (LA) fibrosis. LA fibrosis can be estimated by measuring LA scar using non-invasive imaging methods such as strain imaging in advanced echocardiography and in cardiac magnetic resonance (CMR) imaging. Achieving rhythm control strategy utilising catheter ablation (CA) has shown to be advantageous in improving quality of life (QOL) in patients with paroxysmal AF. The most effective method in management of AF has remained elusive in non-paroxysmal AF. Thoracoscopic surgical ablation (TSA) has been developed over the last decade by experienced surgeons with some promising early results but has not been investigated in long-standing persistent AF (LSPAF). I have attempted to answer some of the relevant questions that have remained in management of LSPAF by conducting a multicentre randomised control trial comparing efficacy between CA and TSA (CASA-AF RCT) and improvements in quality of life indices. In a sub-study, I measured LA volumes using echocardiography and CMR to determine reverse remodelling and LA function using tissue Doppler imaging and strain imaging to predict AF recurrence. In a CMR sub-study, a novel automatic LA segmentation algorithm was used to quantify LA fibrosis before and after ablation. I was able to quantify the response of the autonomic nervous system to targeted ganglionic plexi (GP) ablation as part of TSA compared to CA by measuring heart rate variability. I am hopeful that the knowledge gained from this thesis will help with an appropriate selection that will improve the management of patients with LSPAF.Open Acces