PMC:6019327 / 39881-41476 JSONTXT

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Electrical and Structural Remodeling\nThe pathophysiology of AF is complex, involving interaction among multiple factors, including triggers, which are responsible for AF initiation; substrate, which is necessary for AF maintenance; and perpetuators, which underlie the progression of the arrhythmia from paroxysmal to the persistent forms.146,147 The recently published EHRA/HRS/APHRS/SOLAECE expert consensus document on atrial cardiomyopathies provides a detailed review of the important topic of atrial cardiomyopathies and their interrelationship with AF.148 It is generally believed that some degree of structural remodeling must predate electrical remodeling. The trigger mechanisms can include focal enhanced automaticity or triggered activity. Initiation of AF can be favored by both parasympathetic and sympathetic activation, which also appear to play a role in maintaining AF.149 However, the central mechanisms governing AF initiation and perpetuation are poorly understood, which explains in part why treatment of patients with all forms of AF, and particularly long-standing persistent AF, remains suboptimal. Although AF usually starts with paroxysmal episodes, it can evolve to a persistent form in a significant number of patients.150 A few clinical factors have been associated with transition from paroxysmal to persistent AF.20,151,152 The transition likely reflects progressive structural and electrophysiological remodeling in both atria, making the sources of the arrhythmia more stable by fundamental mechanisms that have been incompletely explored.153,154,155,156"}