Fehmi Keçe

Chapter 9 190 9.2 Future perspectives The number of patients with AF is increasing and it is expected that this number will be doubled in the next 50 years as a consequence of prolonged life expectancy, metabolic syndrome associated diseases and better recovery after (surgical) treatment of cardiac diseases (i.e. myocardial infarction). In the past 20 years, catheter ablation evolved from a rare and difficult procedure to a first-line therapy in many patients with AF. The understanding of the pathogenesis of AF and the equipment and techniques specifically designed for AF ablation improved hand in hand. However, it has also become clear that AF is not just a rhythm disorder that can be treated with a simple intervention. It is quite the opposite, AF is an ongoing multifactorial disease with a very complicated pathophysiology and treatment. Despite the technological development of catheter ablation tools, the incidences of both early and late recurrences after pulmonary vein isolation will remain an important issue, together with ablation safety. The improvement of ablation tools can be challenging but we still believe that optimization of ablation tools and protocols can be successful with better efficacy, reduction of procedural duration and reduction of device-specific complications. In this thesis the results for two randomized clinical trials were described applying improved tools or techniques. Improvement may come in small steps but compared to the very first catheter ablation a huge progress is made. Several diagnostic tools, i.e. high-resolution multi-electrode mapping catheters and imaging techniques, are being developed and implemented to analyze AF. Hereby we are heading to an ablation technique which is primarily based on ‘individual’ substrate analyses. All patients are different and initial substrate-analysis is required, before a specific treatment can be given. This means that we need to adapt a new definition for AF based on the underlying substrate, instead of the arbitrary clinical definitions of paroxysmal and persistent AF. Pulmonary vein isolation, which is currently the cornerstone of the ablation, may become the treatment of just one of the several important pathophysiological mechanisms. Furthermore, more attention is needed for the different pathways responsible for the progression of AF. A more holistic approach is required with attention to patients’ comorbidities (obesity, sleep apnea, hypertension, alcohol abuse, etc.) and underlying individual pathophysiological pathways. The cornerstone of a future ablation procedure will be the understanding and delineation of the substrate, which will be facilitated by high-resolution 3D electro- anatomical mapping systems allowing the integration of anatomical and structural/ functional information from imaging techniques such as magnetic resonance imaging and