New concepts in atrial defibrillation

External cardioversion of atrial fibrillation (AF) is an established and accepted method for termination of individual episodes of AF. Recent advances have taken place in the area of non-pharmacologic management of AF, and despite its long history and well established technique, defibrillation has not been spared from these advances. The success of low-energy internal atrial defibrillation for the termination of both chronic and acute onset has resulted in the development of implantable defibrillators that treat this arrhythmia. Many of the advances have come about as a result of the use of defibrillation in implanted devices for recurrent AF due to the substantial efforts in an attempt to make this form of restoration of sinus rhythm more efficacious and tolerable to the patient. Additionally, the use of other non-pharmacologic control of atrial fibrillation has also been recently explored, namely the use of ablation and atrial pacing. The use of these other non-pharmacologic therapies are likely to both reduce the recurrence rate, as well as enhance the efficacy of defibrillation. However, defibrillation is likely to still be needed to terminate atrial fibrillation for persistent episodes, and its combination with these other therapies is likely synergistic. Electrical therapy to restore sinus rhythm for persistent episodes of AF is likely to be perceived by the patient. Therefore, the concept of patient controlled therapy from implanted devices to treat AF has shown promising results and will likely be a requirement of such devices in the future. Major advances in defibrillation therapy for atrial fibrillation have been made and have resulted in the development of implantable atrial defibrillators. Despite these advances in defibrillation and other therapies for AF, it is likely that combined pharmacologic and non-pharmacologic therapies for AF will prevail over the individual entities themselves. Future study is needed to determine the best therapy or combination of therapies for individual patients with AF.