In this review lecture devoted to nonpharmacologic treatment, Dr. Marchlinski presents a case study illustrating the importance of rate control for more persistent forms of A-fib, noting that in these circumstances, frequency of tachycardia-induced cardiomyopathy should not be underestimated. He describes a French study documenting the triggering mechanism for atrial fibrillation and its origin in atrialization of the pulmonary veins. He discusses HIS bundle ablation in A-fib for patients in whom rate control therapy is inadequate. Ablative therapy for atrial flutter and fibrillation management and catheter ablation of atrial flutter are described as a first line role in management. Successful interruption of the cavo-tricuspid isthmus in A-fib occurs in 98% of patients. Increased use of ablation in atrial flutter, means correct diagnosis of this arrhythmia is crucial.

The author describes the ablation procedure which uses, typically, two catheters being placed in the left atrium. Sites in the right atrium for triggering A-fib include the crista terminalis, Eustachian ridge, and tricuspid annulus in A-fib. The success rate for pulmonary vein isolation procedures in A-fib is detailed. The lecture concludes with a discussion of the risks associated with catheter ablative therapy – which are minimal but serious – and the indications for surgical ablative therapy.