How AF Treatment Has Evolved
An emerging question
Historically, most AF therapies have focused on eliminating the arrhythmia. Increasingly, researchers are asking whether preserving or restoring normal atrial function may become an additional therapeutic goal, particularly in patients with HFpEF.
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2024 ESC Guidelines for the management of atrial fibrillation (Van Gelder, Rienstra et al., Eur Heart J 2024). The most current, comprehensive framework for rate vs rhythm drugs, antiarrhythmic selection, anticoagulation, and the AF-CARE pathway, and the first guideline to recommend SGLT2 inhibitors for HF+AF regardless of EF. For the disease-specific framing, pair it with the Saksena AF-HFpEF review (J Cardiovasc Electrophysiol 2025).
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The long-term outcomes and durability of the Cox-Maze IV procedure for atrial fibrillation (Damiano group, JTCVS 2020). The definitive outcomes paper from the technique's originating group (853 patients, up to 10-year freedom from atrial tachyarrhythmia). If you want a teaching primer on technique/indications first, read Surgical ablation for AF: techniques, indications, and results.
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Atrial Fibrillation Ablation for HFpEF: A Randomized Controlled Trial (Aldaas et al., JACC: Heart Failure 2023). The dedicated AF-HFpEF ablation RCT with invasive exercise hemodynamics, so it teaches both the why (filling-pressure and output gains from restored atrial mechanics) and the outcomes. For the larger outcome signal, add the CABANA HFpEF post-hoc (JACC: Heart Failure 2025).
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Advent of Pulsed Field Ablation for Atrial Fibrillation: State-of-the-Art Review (PMC12781022). A purpose-built teaching review of mechanism (electroporation, myocardial selectivity), safety, and trial data. The pivotal trial is ADVENT (NEJM 2023), now with 4-year ADVENT-LTO data (Nature Medicine 2026).
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2023 HRS/APHRS/LAHRS Guideline on Cardiac Physiologic Pacing (Heart Rhythm 2023). The authoritative reference defining His-bundle and left bundle branch area pacing indications. For a more digestible primer, LBBAP: a new era of cardiac resynchronization therapy? (PMC11439098). Caveat: outcome evidence is largely in reduced-EF/CRT populations, not HFpEF.
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The broadest current overview of the device landscape (interatrial shunts, assist devices, and others).
Atrial shunt therapy for heart failure: an update review (Heart Failure Reviews 2025) and the miniature implantable left atrial/ventricular pump for HFpEF (PMC11733750).