NICE guidance on catheter ablation of atrial fibrillation using an epicardial (non-thorascopic) approach

The recent advent of percutaneous trans-catheter ablation (CA) has provided electrophysiologists with an unprecedented tool for the curative treatment of atrial fibrillation (AF). This technique aims at replicating the highly effective changes of atrial substrate previously introduced by surgery in patients with AF.1 Using a femoral transvenous access, one or more catheters are advanced into the left atrium via a trans-septal puncture and radiofrequency (RF) current is delivered to change the atrial substrate such that AF becomes non-inducible or non-sustained. Since the first report of CA of AF in humans in 1994,2 several techniques with different ablation designs have been introduced in clinical practice.3 4 5 6 7 8 9 The variable rationales inspiring development of these techniques reflected the evolving knowledge on AF pathophysiology and the incomplete ability by each of them to steadily restore sinus rhythm. Using these techniques, investigators could prove that approximately one-half to two-thirds of patients were cured without antiarrhythmic drugs (AADs) and a variable additional proportion was cured by adding previously ineffective AADs. This result does not appear to have improved after the introduction of energy sources alternative to radiofrequency current.10 As a consequence, investigators are still in search of new techniques for further improving patients’ clinical outcome. Among currently investigated techniques, percutaneous epicardial trans-catheter RF ablation offers the …