Challenges and opportunities in improving the management of atrial fibrillation: recent research advances and their clinical translation

Updates in the management of atrial fibrillation: Emerging therapies and treatment

OBJECTIVE

The most common and clinically important cardiac arrhythmia is atrial fibrillation (AF), which has a large negative impact on public health due to higher fatalities, morbidity, and healthcare expenditure rates. This study aims to provide valuable insights into the effectiveness and outcomes of various treatment approaches and interventions for AF.

STUDY DESIGN

Systematic review.

METHOD

The most pertinent published research (original papers and reviews) in the scientific literature were searched for and critically assessed using the online, internationally indexed databases PubMed, Medline, and Cochrane Reviews. These studies are summarised in this review. Keywords like "Atrial Fibrillation", "emerging therapies", "treatment", "catheter ablation", and "atrial appendage" were used to search the papers. The papers were researched and examined to be relevant to the topic.

CONCLUSION

A lot of work has gone into enhancing AF management to deal with this expanding public health concern. Significant developments and advances in the treatment of AF during the past few years have aided clinicians in giving AF patients better care. The most recent treatments for AF include medication, catheter ablation, cryo-balloon ablation, and left atrial appendage closure.

How synergy between mechanistic and statistical models is impacting research in atrial fibrillation

Atrial fibrillation (AF) with multiple complications, high morbidity and mortality, and low cure rates, has become a global public health problem. Although significant progress has been made in the treatment methods represented by anti-AF drugs and radiofrequency ablation, the therapeutic effect is not as good as expected. The reason is mainly because of our lack of understanding of AF mechanisms. This field has benefited from mechanistic and (or) statistical methodologies. Recent renewed interest in digital twin techniques by synergizing between mechanistic and statistical models has opened new frontiers in AF analysis. In the review, we briefly present findings that gave rise to the AF pathophysiology and current therapeutic modalities. We then summarize the achievements of digital twin technologies in three aspects: understanding AF mechanisms, screening anti-AF drugs and optimizing ablation strategies. Finally, we discuss the challenges that hinder the clinical application of the digital twin heart. With the rapid progress in data reuse and sharing, we expect their application to realize the transition from AF description to response prediction.

Mutant ANP induces mitochondrial and ion channel remodeling in a human iPSC-derived atrial fibrillation model

Human induced pluripotent stem cell–derived cardiomyocytes (iPSC-CMs) can model heritable arrhythmias to personalize therapies for individual patients. Although atrial fibrillation (AF) is a leading cause of cardiovascular morbidity and mortality, current platforms to generate iPSC-atrial (a) CMs are inadequate for modeling AF. We applied a combinatorial engineering approach, which integrated multiple physiological cues, including metabolic conditioning and electrical stimulation, to generate mature iPSC-aCMs. Using the patient’s own atrial tissue as a gold standard benchmark, we assessed the electrophysiological, structural, metabolic, and molecular maturation of iPSC-aCMs. Unbiased transcriptomic analysis and inference from gene regulatory networks identified key gene expression pathways and transcription factors mediating atrial development and maturation. Only mature iPSC-aCMs generated from patients with heritable AF carrying the non-ion channel gene (NPPA) mutation showed enhanced expression and function of a cardiac potassium channel and revealed mitochondrial electron transport chain dysfunction. Collectively, we propose that ion channel remodeling in conjunction with metabolic defects created an electrophysiological substrate for AF. Overall, our electro-metabolic approach generated mature human iPSC-aCMs that unmasked the underlying mechanism of the first non-ion channel gene, NPPA, that causes AF. Our maturation approach will allow for the investigation of the molecular underpinnings of heritable AF and the development of personalized therapies.

Find Me If You Can: First Clinical Experience Using the Novel CARTOFINDER Algorithm in a Routine Workflow for Atrial Fibrillation Ablation

Aims: The CARTOFINDER module allows for simultaneous and automated detection of repetitive focal and rotational activations in patients with atrial arrhythmias. This study aimed to validate the CARTOFINDER algorithm for the detection of potential drivers for atrial fibrillation (AF) and to access their potential impact on individual arrhythmia substrates. Methods: Fifty consecutive patients underwent AF ablation for persistent AF (PERS), using a 3D-mapping system with the integrated CARTOFINDER module. Regions of interest (ROIs) were identified before and after ablation, and their spatial and temporal relationship was correlated with areas of fibrosis. Results: Procedural success was achieved in all patients and 42% received ablation beyond pulmonary vein isolation (PVI). AF termination was observed in 6 patients (12%). The mean procedure duration was 134 ± 29 min. ROIs were revealed in all patients (mean n = 77 ± 52) and there was no statistical evidence for a predilection site. There was no significant anatomical correlation between ROIs and bipolar low voltage. Remapping confirmed the elimination of ROIs in relation to the individual ablation site, a limited reproducibility of rotational ROIs and persistent focal activity over time in some anatomical segments. ROIs were not a predictor for AF recurrence during following ablation. Conclusions: CARTOFINDER mapping can be integrated into a routine workflow for AF ablation. ROIs could be discriminated in all patients and an ablation effect was observed in some patients, whereas persistent activity was found in certain anatomical segments, even after ablation. ROIs might be an additional ablation target when we are able to understand the individual substrate.