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.