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When to refer patients for non-pharmacological therapies 

When to refer patients for non-pharmacological therapies
When to refer patients for non-pharmacological therapies
Management of Atrial Fibrillation (Oxford Cardiology Library): A Practical Approach

L. Brent Mitchell


Non-pharmacological alternatives exist to accomplish each of the dominant therapeutic goals in the treatment of the patient with atrial fibrillation (AF). Ventricular response rate control can be achieved by transvenous catheter ablation of the atrioventricular (AV) junction to produce purposeful AV block allowing the ventricular rate to be controlled by an implanted pacemaker. The major advantage of this ablate-and-pace approach is its efficacy; its major disadvantage is relative or absolute pacemaker dependence. Of course, ventricular response rate control may also be achieved by AF rhythm control. The dominant non-pharmacological alternative for AF rhythm control is surgical or transvenous catheter ablation of AF triggers and/or AF maintenance substrates. The major advantage of AF trigger and/or maintenance substrate ablation is the possibility of AF rhythm control without antiarrhythmic drugs; its major disadvantages are lower efficacy and the risks associated with the procedure. Other non-pharmacological alternatives for AF rhythm control include implantable devices designed to prevent or rapidly terminate episodes of AF. The advantages of these devices are most evident in AF patients with indications for pacing because of coexistent bradyarrhythmias; their disadvantages are those of an implanted device. Finally, non-pharmacological approaches to the prevention of AF-related thromboembolic events include surgical and catheter-based techniques designed to exclude the left atrial appendage as a site of thrombus formation. The major advantage of this approach is the potential to obviate the need for anticoagulation therapy; its major disadvantage is the risk of the procedure.

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