Non-pharmacologic therapies currently used to treat atrial fibrillation are categorized into those that control rate, those that maintain sinus rhythm and those that ablate the initiators of atrial fibrillation. Heart rate can be controlled by two methods, AV node ablation with pacemaker or AV node modification without pacemaker. Sinus rhythm can be maintained with adjunctive pacing, implantable atrial defibrillator, surgical maze procedures and catheter ablation.

AV node ablation generates a complete heart block and requires a permanent pacemaker to control heart rate after the procedure. This technique controls symptoms, improves quality of life, decreases the use of anti-arrhythmic medications, reduces hospital admissions and outpatient visits. AV node modification slows AV node conduction just before a complete heart block. For this reason, a permanent pacemaker is not needed. The procedure has the risk of complete heart block because the endpoint is difficult to assess. Studies that compared these two techniques demonstrated more symptom control and fewer hospital visits with AV node ablation. These approaches are indicated for patients whose ventricular rate does not respond to medical therapy; who cannot tolerate medical therapy; whose atrial fibrillation causes exacerbations in heart failure, angina, hypertension or precipitated ventricular fibrillation; and whose treatment of co-morbid illness prevents regulation of atrial fibrillation.

Maintenance of sinus rhythm is best achieved with implantable atrial defibrillators or surgical maze procedures. Implantable atrial defibrillators contain atrial pacing and rate stabilization algorithms and tiered atrial fibrillation therapy built into them. Their use is limited to patients with infrequent episodes of atrial fibrillation and ventricular tachyarrhythmias. Surgical maze procedures limit the capability of the atria to maintain atrial fibrillation once initiated. The most successful and curative procedure is isolation of the pulmonary vein to the mitral annulus. More studies are needed to determine the clinical role of adjunctive pacing and catheter ablation.

Because most initiation sites for atrial fibrillation occur within the pulmonary vein, the pulmonary vein isolation procedure has a success rate of 90% of cure or palliation. This procedure prevents conduction into or out of the vein. The best candidates for this procedure are patients with paroxysmal or persistent atrial fibrillation who are symptomatic and refractory to drugs and have minimal to moderate structural disease. Dr. Wharton believes ablation therapy will be used to cure more cases of atrial fibrillation in the future.