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Size matters in atrial fibrillation: the underestimated importance of reduction of contiguous electrical mass underlying the effectiveness of catheter ablation

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Title: Size matters in atrial fibrillation: the underestimated importance of reduction of contiguous electrical mass underlying the effectiveness of catheter ablation
Authors: Hartley, A
Shalhoub, J
Ng, F
Krahn, A
Laksman, Z
Andrade, J
Deyell, M
Kanagaratnam, P
Sikkel, M
Item Type: Journal Article
Abstract: Evidence has accumulated over the last century of the importance of a critical electrical mass in sustaining atrial fibrillation (AF). AF ablation certainly reduces electrically contiguous atrial mass, but this is not widely accepted to be an important part of its mechanism of action. In this article, we review data showing that atrial size is correlated in many settings with AF propensity. Larger mammals are more likely to exhibit AF. This is seen both in the natural world and in animal models, where it is much easier to create a goat model than a mouse model of AF, for example. This also extends to humans—athletes, taller people, and obese individuals all have large atria and are more likely to exhibit AF. Within an individual, risk factors such as hypertension, valvular disease and ischaemia can enlarge the atrium and increase the risk of AF. With respect to AF ablation, we explore how variations in ablation strategy and the relative effectiveness of these strategies may suggest that a reduction in electrical atrial mass is an important mechanism of action. We counter this with examples in which there is no doubt that mass reduction is less important than competing theories such as ganglionated plexus ablation. We conclude that, when considering future strategies for the ablative therapy of AF, it is important not to discount the possibility that contiguous electrical mass reduction is the most important mechanism despite the disappointing consequence being that enhancing success rates in AF ablation may involve greater tissue destruction.
Issue Date: 1-Nov-2021
Date of Acceptance: 22-Mar-2021
URI: http://hdl.handle.net/10044/1/88615
DOI: 10.1093/europace/euab078
ISSN: 1099-5129
Publisher: Oxford University Press
Start Page: 1698
End Page: 1707
Journal / Book Title: Europace
Volume: 23
Issue: 11
Copyright Statement: © The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology..This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permitsunrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Sponsor/Funder: Wellcome Trust
British Heart Foundation
Funder's Grant Number: RG/16/3/32175
Keywords: Atrial fibrillation
Atrial size
Catheter ablation
Critical mass
Cardiovascular System & Hematology
1103 Clinical Sciences
Publication Status: Published
Online Publication Date: 2021-05-05
Appears in Collections:Department of Surgery and Cancer
National Heart and Lung Institute
Faculty of Medicine

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