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Contemporary management of persistent atrial fibrillation
  1. Dhiraj Gupta,
  2. Wern Yew Ding
  1. Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
  1. Correspondence to Dr Dhiraj Gupta, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; dhiraj.gupta{at}

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Learning objectives

  • Develop a basic understanding of the underlying mechanisms of atrial fibrillation and classification of the disease.

  • Review the main principles in contemporary management of atrial fibrillation with a focus on persistent atrial fibrillation.

  • Discuss catheter ablation in the context of atrial fibrillation.


Atrial fibrillation (AF) is a multisystemic disorder that is associated with an excess risk of stroke, heart failure and mortality.1 It remains the most common sustained arrhythmia and its significance should not be underestimated. Research focused on unveiling the mechanisms of AF began over a century ago. During this period, several theories have been proposed. More recently, the notion of rotors and spiral waves propagating in the atria was used to address the flaws of prior concepts and enhance our understanding on the development of AF.2 3 Presently, it is believed that the initiation and maintenance of AF is linked to a complex interplay between two crucial components: ‘trigger’ and ‘substrate’. The former refers to one or more ectopic foci that initiate rapid electrical activity resulting in depolarisation of surrounding cardiac myocytes. Maintenance of AF is subsequently dependent on the presence of a suitable substrate in terms of electrophysiological, mechanical and anatomical properties.4 The biggest breakthrough in our understanding of AF occurred two decades ago when Haïssaguerre et al demonstrated the role of pulmonary veins as the most common sites of triggers for the disease.5 This observation serves as the fundamental basis for ablation therapy for AF.

In practice, AF is frequently diagnosed following an incidental finding of uncoordinated atrial activation on a timely surface ECG; subsequent classification of the disease is based on temporal rhythm-based patterns (table 1).6 The latter concept stems from the idea that many patients who develop AF initially suffer from paroxysmal episodes due to triggers that promote …

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  • Contributors WYD drafted the manuscript and prepared the Figures/Tables. DG revised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests DG: speaker for Boehringer Ingelheim, Biosense Webster and Boston Scientific. Proctor for Abbott. Research Grants from Medtronic, Biosense Webster and Boston Scientific. WYD: None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Author note References which include a * are considered to be key references.