Catheter ablation: Ablation is a newer technique and has shown great promise for cases of recurrent AF that are unresponsive to conventional treatments. Radiofrequency ablation (RFA) uses radiofrequency energy to destroy abnormal electrical pathways in heart tissue. The energy emitting probe (electrode) is placed into the heart through a catheter inserted into veins in the groin or neck. Electrodes that can detect electrical activity from inside the heart are also inserted, and the electrophysiologist uses these to "map" an area of the heart in order to locate the abnormal electrical activity before eliminating the responsible tissue. Similar ly other sources of energy like High Intensity Focussed Ultrasound (HIFU), Laser energy and cryo energy are also being evaluated.

AV node ablation: In patients with AF where rate control drugs are ineffective and it is not possible to restore sinus rhythm using cardioversion, non-pharmacological alternatives are available. For example, to control rate it is possible to destroy the bundle of cells connecting the upper and lower chambers of the heart - the atrioventricular node - which regulates heart rate, and to implant a pacemaker instead. A more complex technique, which avoids the need for a pacemaker, involves ablating groups of cells near the pulmonary veins where atrial fibrillation is thought to originate, or creating more extensive lesions in an attempt to prevent atrial fibrillation from establishing itself. Prior to the development of the current AF ablation strategies Ablate and Pace used to be the only available intervention for patients with difficult to control heart rates despite maximal medial therapy. These days, patients who don't meet criteria for AF ablation, elderly patients who are too frail for invasive procedures, massively dilated chambers with extensive scarring are some of the situations where Ablate and Pace is still used as a treatment strategy.

Pulmonary vein isolation: This approach has redefined the fundamentals of the approach AF treatment. Since the discovery of the role of pulmonary vein and non pulmonary vein foci, attempts of these foci has been met with varying success. In the beginning, ablation was done inside the PVs causing significant symptomatic narrowing of these structures (PV stenosis). So a more ostial approach closer to the opening was adapted and subsequently a wider encircling lesion at the broad funnel shaped area called antrum has been adapted with greater success and minimal risk of PV stenosis. Most AF ablations consist of isolating the electrical pathways from the pulmonary veins (PV), preventing the electrical activity generated inside the PVs from entering the left atrium. All other veins from the body (including neck and groin) lead to the right atrium, so in order to get to the left atrium the catheters must get across the atrial septum. This is done by piercing a small hole in the septal wall. This is called a transseptal approach. Once in the left atrium, the physician may perform the PV isolation. There are physicians who use the single catheter technique in conjunction with a 3D electroanatomic mapping system like CARTO or NAVX and do a pure anatomic burn around all the PVs. And then there are physicians who use double transseptal puncture with two catheters in the left atrium. The circular mapping catheter helps to navigate the left atrium with minimal trauma and identify the PV-left atrial junction and locate the electrical connections based on the activity recorded on their electrodes. Then the second catheter is typically the ablation catheter with a metallic tip that can heat up with radiofrequency energy . this catheter can burn the tissue and help in creating the isolation lesions.

Frequently for patients with paroxysmal AFib isolation of the PVs and SVC or IVC should result in excellent rhythm control. In patients with more persistent and permanent forms of AFib there are sites more complex electrical activity suggestive of possible sites of rotor activity. Some more recent approaches to ablating AF is to target sites that are particularly disorganized in both atria as well as in the coronary sinus (CS). These sites are termed complex fractionated atrial electrogram (CFAE) sites. It is believed by some that the CFAE sites are the cause of AF, or a combination of the PVs and CFAE sites are to blame. New techniques include the use of cryoablation (tissue freezing using a coolant which flows through the catheter), microwave ablation, where tissue is ablated by the microwave energy "cooking" the adjacent tissue, and high intensity focused ultrasound (HIFU), which destroys tissue by heating. This is an area of active research, especially with respect to the RF ablation technique and emphasis on isolating the pulmonary veins that enter into the left atrium.

Efficacy and risks of catheter ablation of atrial fibrillation are areas of active debate. Results are widely variable, due in part to differences in technique, follow-up, definitions of success, use of antiarrhythmic therapy, and in experience and technical proficiency. Bleeding, hematoma, cardiac perforation, cardiac tamponade, stroke, catheter entrapment, myocardial infarction, pulmonary vein stenosis, atrio-esophageal fistula (connection between the esophagus and the left atrium), atrio-bronchial fistula (connection between the atrium and air ways), diaphragmatic paralysis (due to damage to the phrenic nerve), iatrogenic atrial tachycardias (due to incomplete lines of block) are some of the potential risks of this invasive procedure. In a smaller percentage of patients a redo ablation may be required to address the underlying arrhythmia. Resumption of conduction across the PVs enabling the triggered activity to trickle down into the left atrium or atrial tachycardias often times need redo ablation. A second procedure dramatically increases the success rates of the ablation procedure.

Surgical Maze procedure: James Cox, MD, and associates developed the Cox maze procedure, an open-heart surgical procedure intended to eliminate atrial fibrillation, and performed the first one in 1987. "Maze" refers to the series of incisions made in the atria, which are arranged in a maze-like pattern. The intention was to eliminate AF by using incisional scars to block abnormal electrical circuits (atrial macroreentry) that AF requires. This procedure required an extensive series of endocardial (from the inside of the heart) incisions through both atria, a median sternotomy (vertical incision through the breastbone) and cardiopulmonary bypass (heart-lung machine). A series of improvements were made, culminating in 1992 in the Cox maze III procedure, which is now considered to be the "gold standard" for effective surgical cure of AF. The Cox maze III is sometimes referred to as the "traditional maze", the "cut and sew maze", or simply the "maze". Frequently AF patients who undergo open heart procedures for valve repair or replacement, coronary artery bypass grafting are considered for concomitant MAZE or surgical PV isolation procedure with LAA ligation . With advances in catheter based interventions primary MAZE surgery has become less frequent due to morbidity related to open heart surgery.

Minimaze surgery is minimally invasive cardiac surgery similarly intended to address atrial fibrillation. The "minimaze" procedures are "mini" versions of the original Cox maze procedure. These procedures are less invasive than the Cox maze procedure and do not require a median sternotomy (vertical incision in the breastbone) or cardiopulmonary bypass (heart-lung machine). They use microwave, radiofrequency, or acoustic energy to ablate atrial tissue near the pulmonary veins. Pulmonary veins are isolated anatomically from the epicardial surface. Recent addition of electrophysiologic assessment at the time of surgery has helped this technique make significant inroads in being an effective treatment option.

Left atrial appendage closure devices: This experimental device has been studied and was found to be useful in reducing the risk of stroke in patients with permanent AF who cannot be anticoagulated The occluder device is embedded into the LAA at its opening closing of the appendageal cavity from the rest of the left atrium. Over a period of time the device endothelializes and the LAA shrinks. This device is in line for FDA approval for use in non study patients soon.