Spiriti Giulia, Scarà Antonio, Borrelli Alessio, Zanin Federico, Pignalosa Leonardo, Buzzelli Lorenzo, Palamà Zefferino, Robles Antonio Gianluca, Nesti Martina, Sciarra Luigi
Unit of Cardiac Electrophysiology, San Carlo di Nancy Hospital, 00165 Rome, Italy.
Department of Life, Health and Environmental Sciences, University of L'Aquila, 67100 L'Aquila, Italy.
J Clin Med. 2025 Sep 19;14(18):6601. doi: 10.3390/jcm14186601.
Atrial fibrillation (AF) is the most common sustained supraventricular arrhythmia, affecting 2-3% of the adult population and contributing significantly to morbidity, mortality, and healthcare burden. Catheter ablation has become a cornerstone in the treatment of symptomatic, drug-refractory AF, with pulmonary vein isolation (PVI) established as the standard approach, especially in paroxysmal AF. Over the past three decades, ablation technologies have evolved considerably-from radiofrequency and cryoballoon to the recent advent of pulsed field ablation-enhancing procedural safety, efficiency, and lesion durability. Despite these technological advancements, long-term outcomes have plateaued, suggesting that success may depend not just solely on the energy source used, but also on a more individualized, mechanism-based approach. The classification of AF based on duration alone fails to capture the complexity of its underlying pathophysiology. Tailored strategies that consider arrhythmic mechanisms, electrophysiological triggers, and patient-specific substrates-especially in persistent AF-are increasingly recognized as essential for durable results. Tools such as high-density mapping, autonomic modulation, and substrate-targeted ablation are expanding therapeutic horizons. Moreover, special populations, such as athletes, present unique arrhythmic profiles influenced by structural and autonomic remodeling, requiring nuanced management. The integration of lifestyle interventions, neuromodulation techniques, and emerging genetic and pharmacological insights further supports a comprehensive, personalized approach. In this paper, we explore whether future success in AF ablation lies more in refining technology or in advancing our understanding of arrhythmic mechanisms to guide patient-specific therapy.
心房颤动（AF）是最常见的持续性室上性心律失常，影响2%-3%的成年人口，并对发病率、死亡率和医疗负担有显著影响。导管消融已成为有症状、药物难治性AF治疗的基石，肺静脉隔离（PVI）已成为标准方法，尤其是在阵发性AF中。在过去三十年中，消融技术有了很大发展——从射频和冷冻球囊到最近脉冲场消融的出现——提高了手术安全性、效率和病变持久性。尽管有这些技术进步，但长期结果已趋于平稳，这表明成功可能不仅取决于所使用的能量源，还取决于更个体化、基于机制的方法。仅根据持续时间对AF进行分类无法捕捉其潜在病理生理学的复杂性。考虑心律失常机制、电生理触发因素和患者特异性基质的定制策略——尤其是在持续性AF中——越来越被认为是取得持久效果的关键。诸如高密度标测、自主神经调节和基质靶向消融等工具正在拓展治疗视野。此外，特殊人群，如运动员，呈现出受结构和自主神经重塑影响的独特心律失常特征，需要细致的管理。生活方式干预、神经调节技术以及新兴的基因和药理学见解的整合进一步支持了全面、个性化的方法。在本文中，我们探讨AF消融未来的成功更多地在于改进技术还是在于加深我们对心律失常机制的理解以指导针对患者的治疗。
