[Interventional management of atrial fibrillation]

In 2030, the European Union will include 14 to 17 million atrial fibrillation (AF) patients, with 120,000 to 215,000 new cases each year. The increase in the prevalence of this arrhythmia has led to the development of new therapeutic intervention strategies to manage the different aspects of this disease. Thus, endocavitary or epicardial ablation of AF, by radiofrequency or cryoablation, provides superior results to antiarrhythmic therapy in controlling symptoms and preventing heart failure in paroxysmal or persistent AF. In heart failure patients with advanced AF, the ablation of the atrioventricular junction associated with the implantation of a bi-ventricular pacemaker has just demonstrated its clear superiority, bringing this technique up to date. Finally, in the event of a major bleeding risk and contraindication to anticoagulants, percutaneous occlusion of the left atrium has proven its value in preventing AF-related embolic events. The future will certainly see the emergence of new technologies but also personalized strategies based on an optimal selection of the right candidates for these interventions, thanks in particular to the contribution of imaging before the procedure.

[Left atrial appendage closure and embolic events]

Atrial fibrillation (AF) is frequent and responsible for embolic events. Currently, the gold standard to prevent such embolic events is anticoagulant therapy with vitamin K antagonist (VKA) or direct oral anticoagulant in nonvalvular AF. Recently, left atrial appendage closure was proposed as an alternative to anticoagulant inpatient with high embolic risk and contraindication to anticoagulant therapy. Data from randomized trials were consistent with a non-inferiority of left atrial appendage closure in comparison to VKA in terms of stroke and cardiovascular death. However, despite improvements in procedure results and complications reduction, this invasive strategy has to be performed with optimal security as this strategy is a preventive treatment in high-risk patients. These improvements may allow an extension of indications of left atrial appendage closure to lower profile risk patients as an alternative to anticoagulant. Indeed, anticoagulant is a risky therapy with hemorrhagic events and observance is a real issue in an asymptomatic population. Finally, there is a lack of data in recent literature comparing left atrial appendage closure to direct oral anticoagulant, widely used in daily practice, as well as cost-effectiveness of this procedure in comparison to anticoagulant.