Surgical perspectives in the management of atrial fibrillation

Table 2 Comparing and contrasting the various available ablation modalitie

Ablationmodality	Mode of action	Advantages	Complications	Transmural lesions	Current limitations
RFA	Controlled thermal damage and lesions caused by electrical current	Less operating time Reduced technical difficulty	Intercavity thrombus Pulmonary vein stenosis Oesophageal and coronary artery injury	Variable	Confirmation of transmurality Variation between instruments
Cryoablation	Targeted scarring by cooling tissue using high-pressure argon and helium Initial cellular destruction followed by fibrosis and full thickness disruption	Visual confirmation of transmurality Less damage to surrounding tissues and vascularity Less endocardial thrombus Electrical isolation of atria	Coronary artery and phrenic nerve injury Atrioesophageal fistula	Yes	Variable success rate
Microwave	Production of lesions by thermal injury	Minimal collateral damage Minimal scar formation Lower risk of VTE	Coronary artery damage potential	Variable	Less effective compared to other modalities Limited evidence
HIFU	Creation of localised hyperthermic lesions using a focused beam of ultrasound energy	Fast epicardial lesions Future potential advantage visualisation of thickness by ultrasound and tailor made lesions	Atrioesophageal fistula Pericardial effusion Phrenic nerve injury	Yes endocardial only	High rate of complications Limited evidence currently not recommended outside trials
Laser	Use of high energy optical beams to create thermal lesions	Well demarcated lesions Non-arrythmogenic Rapid lesions	Crater formation Perforation Tissue loss Poor visibility of scar	Yes	Limited evidence currently not recommended outside trials

RAF: Radiofrequency ablation; HIUF: High intensity focused ultrasound.