NONPHARMACOLOGIC THERAPIES FOR ATRIAL-FIBRILLATION

The limited efficacy and proarrhythmic risks of antiarrhythmic drug th erapies for atrial fibrillation have led to the exploration of a wide spectrum of alternative therapeutic approaches. The diversity of the a pproaches is warranted by the current absence of a single procedure th at can safety and effectively cure atrial fibrillation. The interventi onal therapies that are currently under most active development includ e implantable atrial defibrillator therapy, prophylactic atrial pacing in combination with drug therapy, multisite regional pace-entrainment of atrial fibrillation by rapid pacing, atrial surgery, and catheter ablation for atrial fibrillation. The current limitations of these pro cedures include: (1) for the implantable atrial defibrillator-patient tolerance of low energy shocks and early recurrence of atrial fibrilla tion; (2) for prophylactic pacing-limited efficacy in a small proporti on of the total atrial fibrillation population; (3) for multisite regi onal pace-entrainment-lack of proved efficacy and difficulty in the ex pansion and merging of the entrained regions; (4) for atrial surgery-h ighly invasive as a stand-alone procedure; and (5) for catheter ablati on-lack of proved long-term efficacy, shortcomings of currently availa ble technology, and risk of thromboembolic stroke. It is evident that more basic and clinical research as well as technologic innovation are needed. However, it is likely that some of these new therapies, possi bly in combination with antiarrhythmic drug therapy, will offer consid erable clinical benefit to selected patients with symptomatic atrial f ibrillation. (C) 1998 by Excerpta Medica, Inc.