Conclusion

Adverse atrial remodeling plays a large part in the tendency for AF to persist with time. While the AF substrate and atrial fibrosis are commonly used interchangeably, and low voltage is often taken to represent this during electro-anatomical mapping. In reality the arrhythmogenic substrate is multi-faceted and highly complex. Reductions in atrial voltage reflect fibrosis, a process that is not uniform, but also altered electrical properties of myocardiocytes. Moreover, atrial voltage is significantly influenced by the technical approach to electro-anatomical mapping. Recent technological advances have renewed interest in substrate modification, and bridge the gap in the ablative management of paroxysmal and persistent AF. Finally, adverse atrial remodeling is a dynamic and progressive process, driven by upstream risk factors. Without adequate risk factor modification, ongoing substrate development and AF recurrence is likely, stressing the importance of a holistic approach to AF care.