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Fig. 9. Distribution of focal initiators of AF in the left and right atrium. (Reproduced with permission.)

Fig. 9. Distribution of focal initiators of AF in the left and right atrium. (Reproduced with permission.)

frequency of painful shocks. Combined atrial-ventricular ICDs would offer more freedom in choosing and dosing antiarrhythmic drug therapy, because ventricular proar-rhythmia can be treated with the ventricular defibrillator. These approaches can be considered "hybrid approaches," because they combine pharmacological and nonphar-macological therapies. Ablation approaches may also result in palliation of AF in conjunction with continued medical therapy. Hybrid ablation approaches include ablation of typical atrial flutter in patients with AF and antiarrhythmic drug-induced atrial flutter (114), focal AF ablation in patients with persistent AF and early recurrence of AF after cardioversion (ERAF) (111), and right-sided maze procedures (96,97,101,102). Ablation approaches can also be used in patients with persistent AF to decrease the frequency of AF and to increase the acceptance of an IAD. The myriad possibilities of hybrid therapy are just beginning to be evaluated, but may provide many potential useful options in the future.

Substantial progress has been made in the last decade in providing a number of nonpharmacological options for treating AF. As it is recognized that AF is a chronic illness and that "atrial fibrillation begets atrial fibrillation," (115) efforts to maintain sinus rhythm will become more aggressive. The role of each of the nonpharmacological options discussed in this chapter relative to each other has not been determined, and the optimal patient groups for each approach have not been fully established. It is possible that some types of AF will respond to one approach and not another. However, further progress must be made in understanding the various pathogenetic factors responsible for the syndrome of AF before optimal nonpharmacological therapy can be prescribed.

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