Substrate Modification in Catheter Treatment of Atrial Fibrillation

Keywords: arrhythmia, atrial fibrillation, catheter destruction, arrhythmogenesis, pulmonary vein isolation, fibrous substrate


According to modern concepts, atrial fibrillation (AF) occurs when there are triggers affecting the prepared substrate (atrial myocardium) in the presence of modulating factors that contribute to the occurrence of arrhythmia. Catheter treatment of AF has been most successfully developed in the field of affecting triggers (since late 1990s, the most successful was a technique of isolation of pulmonary veins which are the main source of trigger impulses in AF). Over the past two decades, various techniques have also been proposed for influencing the fibrous substrate.

The aim. To analyze the most advanced techniques for influencing the fibrous substrate during catheter treatment of AF.

Materials and methods. We analyzed the experience of leading electrophysiological centers in this field.

Discussion. Modern studies contain various electrophysiological criteria of fibrous myocardium. However, the signal amplitude less than 0.5 mV is considered borderline between healthy and damaged tissues by most authors. The task of the catheter action on the myocardium is to separate the fibrously altered tissue and intact tissue. This can be achieved by isolating the area of fibrosis or by transforming it into a scar tissue incapable of arrhythmogenesis. It should be noted that both methods are associated with the same frequency of the absence of AF paroxysms, which can be regarded as confirmation of the advisability of influencing the substrate. The most important is that exposure of the substrate can significantly reduce the recurrence rate of AF compared to that when the ablation procedure is limited to isolation of the pulmonary veins.

Conclusions. Modern methods of influencing the areas of fibrosis in the atria can significantly improve the results of catheter treatment of AF.


  1. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373-498.
  2. Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14(10):e275-e444.
  3. Verma A, Wazni OM, Marrouche NF, Martin DO, Kilicaslan F, Minor S, Schweikert RA, Saliba W, Cummings J, Burkhardt JD, Bhargava M, Belden WA, Abdul-Karim A, Natale A. Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation: an independent predictor of procedural failure. J Am Coll Cardiol. 2005;45(2):285-292.
  4. Marrouche NF, Wilber D, Hindricks G, Jais P, Akoum N, Marchlinski F, Kholmovski E, Burgon N, Hu N, Mont L, Deneke T, Duytschaever M, Neumann T, Mansour M, Mahnkopf C, Herweg B, Daoud E, Wissner E, Bansmann P, Brachmann J. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA. 2014;311(5):498-506.
  5. Arbelo E, Brugada J, Blomström-Lundqvist C, Laroche C, Kautzner J, Pokushalov E, Raatikainen P, Efremidis M, Hindricks G, Barrera A, Maggioni A, Tavazzi L, Dagres N; on the behalf of the ESC-EHRA Atrial Fibrillation Ablation Long-term Registry Investigators. Contemporary management of patients undergoing atrial fibrillation ablation: in-hospital and 1-year follow-up findings from the ESC-EHRA atrial fibrillation ablation long-term registry. Eur Heart J. 2017;38(17):1303-1316.
  6. Rolf S, Kircher S, Arya A, Eitel C, Sommer P, Richter S, Gaspar T, Bollmann A, Altmann D, Piedra C, Hindricks G, Piorkowski C. Tailored atrial substrate modification based on low-voltage areas in catheter ablation of atrial fibrillation. Circ Arrhythm Electrophysiol. 2014;7(5):825-833.
  7. Kircher S, Arya A, Altmann D, Rolf S, Bollmann A, Sommer P, Dagres N, Richter S, Breithardt OA, Dinov B, Husser D, Eitel C, Gaspar T, Piorkowski C, Hindricks G. Individually tailored vs. standartized substrate modification during radiofrequency catheter ablation for atrial fibrillation: a randomized study. Europace. 2018;20(11):1766-1775.
  8. Kapa S, Desjardins B, Callans DJ, Marchlinski FE, Dixit S. Contact electroanatomic mapping derived voltage criteria for characterizing left atrial scar in patients undergoing ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2014;25(10):1044-1052.
  9. Kottkamp H, Bender R, Berg J. Catheter ablation of atrial fibrillation: how to modify the substrate? J Am Coll Cardiol. 2015;65(2):196-206.
  10. Kottkamp H, Schreiber D, Moser F, Rieger A. Therapeutic approaches to atrial fibrillation ablation targeting atrial fibrosis. JACC Clin Electrophysiol. 2017;3(7):643-653.
  11. Jadidi AS, Lehrmann H, Keyl C, Sorrel J, Markstein V, Minners J, Park CI, Denis A, Jaïs P, Hocini M, Potocnik C, Allgeier J, Hochholzer W, Herrera-Siklody C, Kim S, Omri YE, Neumann FJ, Weber R, Haïssaguerre M, Arentz T. Ablation of persistent atrial fibrillation targeting low-voltage areas with selective activation characteristics. Circ Arrhythm Electrophysiol. 2016;9(3):e002962.
  12. Yang G, Yang B, Wei Y, Zhang F, Ju W, Chen H, Li M, Gu K, Lin Y, Wang B, Cao K, Kojodjojo P, Chen M. Catheter ablation of nonparoxysmal atrial fibrillation using electrophysiologically guided substrate modification during sinus rhythm after pulmonary vein isolation. Circ Arrhythm Electrophysiol. 2016;9(2):e003382.
  13. Yagishita A, Gimbel JR, DE Oliveira S, Manyam H, Sparano D, Cakulev I, Mackall J, Arruda M. Long-Term Outcome of Left Atrial Voltage-Guided Substrate Ablation During Atrial Fibrillation: A Novel Adjunctive Ablation Strategy. J Cardiovasc Electrophysiol. 2017;28(2):147-155.
  14. Yamaguchi T, Tsuchiya T, Nakahara S, Fukui A, Nagamoto Y, Murotani K, Eshima K, Takahashi N. Efficacy of Left Atrial Voltage-Based Catheter Ablation of Persistent Atrial Fibrillation. J Cardiovasc Electrophysiol. 2016;27(9):1055-1063.
How to Cite
Stychynskyi, O. S., Topchii, A. V., & Almiz, P. O. (2021). Substrate Modification in Catheter Treatment of Atrial Fibrillation. Ukrainian Journal of Cardiovascular Surgery, (3 (44), 76-79.