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Atrial fibrillation
Ablation of atrial fibrillation: for whom and how?
  1. Paulus Kirchhof,
  2. Lars Eckardt
  1. Department of Cardiology and Angiology, University Hospital Münster, Germany
  1. Correspondence to Professor Paulus Kirchhof, Medizinische Klinik und Poliklinik C, Kardiologie und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Straße 33, D-48149 Münster, Germany; kirchhp{at}

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Atrial fibrillation (AF) is the most common sustained arrhythmia. Approximately seven million people suffer from AF in Europe, and it is likely that several more millions suffer from ‘silent’, undiagnosed AF.1 w1–w3 Once AF has manifested, it is usually a chronically progressing arrhythmia (figure 1A). The presence of AF, especially of long periods of the arrhythmia, causes pronounced electrical and structural alterations in the atria, thereby perpetuating AF and promoting its recurrence. In addition, chronic underlying comorbidities, a genetic predisposition to AF, and ‘natural’ ageing processes remodel the atria and contribute to the initiation and progression of AF (figure 1B).

Figure 1

(A) ‘Natural’ time course of atrial fibrillation (AF) in a patient. Before the diagnosis of AF, most patients probably experience asymptomatic episodes of the arrhythmia. With the exception of rare patients with ‘true lone AF’, AF recurrences become longer and more frequent over time, and finally result in chronic forms of AF. The majority of patients progresses from persistent AF—that is, AF that is managed by rhythm control interventions—to long lasting persistent AF and finally permanent or accepted AF that is managed by rate control and antithrombotic therapy. Reproduced with permission from Kirchhof et al.1 (B) Different ‘vicious circles’ that contribute to AF. In addition to electrical triggers, often located in the pulmonary veins and the posterior left atrium (red circle), shortening of the atrial action potential can promote multiple wavelet reentry (blue circle), and structural remodelling of the atria contributes to conduction disturbances and electrical isolation of atrial myocardium (green circle). Furthermore, there is a bidirectional interaction between left ventricular dysfunction and atrial dysfunction (brown circle) in AF patients. Unfortunately, only a part of the atrial damage can be prevented by preventing AF (black pie piece), while other parts are due to other, often extracardiac …

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  • Competing interests In compliance with EBAC/EACCME guidelines, all authors participating in Education in Heart have disclosed potential conflicts of interest that might cause a bias in the article. The authors have received honoraria for advice and presentations from several drug and medical device companies involved in management of atrial fibrillation, and received research grants DFG, BMBF, Fondation Leducq, and European Union in addition to research support from industry.

  • Provenance and peer review Commissioned; not externally peer reviewed.