Diagnosis

Treatment

Document Overview

Design and created by Guideline Central in participation with the Heart Rhythm Society.

Catheter and Surgical Ablation of Atrial Fibrillation

Heart Rhythm Society

Publication Date: Apr 8, 2024

Page Last Updated: May 5, 2026

^a A decision to perform AF ablation in an asymptomatic patient requires additional discussion with the patient as the potential benefits of the procedure for the patient without symptoms are uncertain.

Class of Recommendations and Level of Evidence

Class (Strength) of Recommendation
CLASS I (STRONG)Benefit >>> Risk
Suggested phrases for writing recommendations: Is recommended Is indicated/useful/effective/beneficial Should be performed/administered/other Comparative-Effectiveness Phrases^†: Treatment/strategy A is recommended/indicated in preference to treatment B Treatment A should be chosen over treatment B
CLASS IIa (MODERATE) Benefit >> Risk
Suggested phrases for writing recommendations: Is reasonable Can be useful/effective/beneficial Comparative-Effectiveness Phrases^†: Treatment/strategy A is probably recommended/indicated in preference to treatment B It is reasonable to choose treatment A over treatment B
CLASS IIb (WEAK) Benefit ≥ Risk
Suggested phrases for writing recommendations: May/might be reasonable May/might be considered Usefulness/effectiveness is unknown/unclear/uncertain or not well established
CLASS III: No Benefit (MODERATE) (Generally, LOE A or B use only) Benefit = Risk
Suggested phrases for writing recommendations: Is not recommended Is not indicated/useful/effective/beneficial Should not be performed/administered/other
CLASS III: Harm (STRONG) Risk > Benefit
Suggested phrases for writing recommendations: Potentially harmful Causes harm Associated with excess morbidity/mortality Should not be performed/administered/other

Level (Quality) of Evidence^‡
LEVEL A
High-quality evidence^‡ from more than 1 RCT Meta-analyses of high-quality RCTs One or more RCTs corroborated by high-quality registry studies
LEVEL B-R (Randomized)
Moderate-quality evidence^‡ from 1 or more RCTs Meta-analyses of moderate-quality RCTs
LEVEL B-NR (Nonrandomized)
Moderate-quality evidence^‡ from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies Meta-analyses of such studies
LEVEL C-LD (Limited Data)
Randomized or nonrandomized observational or registry studies with limitations of design or execution Meta-analyses of such studies Physiological or mechanistic studies in human subjects
LEVEL C-EO (Expert Opinion)
Consensus of expert opinion based on clinical experience

COR and LOE are determined independently (any COR may be paired with any LOE).

A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).
^† For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
^‡ The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.

COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, randomized; RCT, randomized controlled trial.

Document Overview

Document Title: Catheter and Surgical Ablation of Atrial Fibrillation

Authoring Society: Heart Rhythm Society

Document Publication Date: Apr 8, 2024

Page Last Reviewed/Updated: May 5, 2026

Document Type: Consensus Statement

Country of Publication: Global

Full Text Freely Available: Yes

Full Text Guideline: www.heartrhythmjournal.com/article/S1547-5271(24)00261-3/fulltext

Source Citation: Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY, Steven D, Agbayani MJ, Jared Bunch T, Chugh A, Díaz JC, Freeman JV, Hardy CA, Heidbuchel H, Johar S, Linz D, Maesen B, Noseworthy PA, Oh S, Porta-Sanchez A, Potpara T, Rodriguez-Diez G, Sacher F, Suwalski P, Trines SA. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2024 Mar 30;26(4):euae043. doi: 10.1093/europace/euae043. PMID: 38587017; PMCID: PMC11000153.

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Document Objectives: The objective of this consensus document is to provide practical guidance and set standards in the selection and management (preprocedural, procedural, and postprocedural) of patients considered for or undergoing atrial fibrillation (AF) ablation. Specific sections are devoted to AF pathophysiology, anatomical considerations, evaluation and management of complications, training, and institutional requirements for AF ablation.

Scope: Diagnosis, Treatment

Diseases/Conditions (MeSH)

D001281 - Atrial Fibrillation

D020517 - Atrial Appendage

D001282 - Atrial Flutter

D013612 - Tachycardia, Ectopic Atrial

D001281 - Atrial Fibrillation

D020517 - Atrial Appendage

D001282 - Atrial Flutter

D013612 - Tachycardia, Ectopic Atrial

Keywords: Atrial tachycardia, ablation, anticoagulation, arrhythmia, atrial fibrillation, atrial flutter, catheter ablation, stroke, surgical ablation

Target Patient Population: patients considered for or undergoing atrial fibrillation (AF) ablation

Inclusion Criteria: Male, Female, Adult, Older Adult

Health Care Settings: Hospital, Operating and Recovery Room

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Supplemental Methodology Resources: Data Supplement Data Supplement

Catheter and Surgical Ablation of Atrial Fibrillation

Diagnosis

Table 2a. Indications for Catheter Ablation of Atrial Fibrillation

Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication

Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class 1 or 3 antiarrhythmic medication

Table 2b. Indications for Atrial Fibrillation Ablation in Populations of Patients Not Well Represented in Clinical Trials

Congestive heart failure

Older patients (>75 years of age)

Hypertrophic cardiomyopathy

Young patients (<45 years of age)

Tachy-brady syndrome

Athletes with AF

Asymptomatic AF^a

Table 2c. Indications for Concomitant Open (such as Mitral Valve) Surgical Ablation of Atrial Fibrillation

Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication

Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class 1 or 3 antiarrhythmic medication

Table 2d. Indications for Concomitant Closed (such as CABG and AVR) Surgical Ablation of Atrial Fibrillation

Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication

Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class 1 or 3 antiarrhythmic medication

Table 2e. Indications for Stand-Alone and Hybrid Surgical Ablation of Atrial Fibrillation

Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication

Treatment

Table 3. Atrial Fibrillation Ablation: Strategies, Techniques, and Endpoints

PVisolation by catheter ablation

Ablation strategies to be considered for use in conjunction with PV isolation

Ablation strategies to be considered for use in conjunction with PV isolation

Nonablation strategies to improve outcomes

Strategies to reduce the risks of AF ablation

Table 4. Anticoagulation Strategies: Pre-, During, and Post-Catheter Ablation of AF

Preablation

During ablation

Postablation

Class of Recommendations and Level of Evidence

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology

Catheter and Surgical Ablation of Atrial Fibrillation

Diagnosis

Table 2a. Indications for Catheter Ablation of Atrial Fibrillation

Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication

Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class 1 or 3 antiarrhythmic medication

Table 2b. Indications for Atrial Fibrillation Ablation in Populations of Patients Not Well Represented in Clinical Trials

Congestive heart failure

Older patients (>75 years of age)

Hypertrophic cardiomyopathy

Young patients (<45 years of age)

Tachy-brady syndrome

Athletes with AF

Asymptomatic AFa

Table 2c. Indications for Concomitant Open (such as Mitral Valve) Surgical Ablation of Atrial Fibrillation

Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication

Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class 1 or 3 antiarrhythmic medication

Table 2d. Indications for Concomitant Closed (such as CABG and AVR) Surgical Ablation of Atrial Fibrillation

Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication

Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class 1 or 3 antiarrhythmic medication

Table 2e. Indications for Stand-Alone and Hybrid Surgical Ablation of Atrial Fibrillation

Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication

Treatment

Table 3. Atrial Fibrillation Ablation: Strategies, Techniques, and Endpoints

PVisolation by catheter ablation

Ablation strategies to be considered for use in conjunction with PV isolation

Ablation strategies to be considered for use in conjunction with PV isolation

Nonablation strategies to improve outcomes

Strategies to reduce the risks of AF ablation

Table 4. Anticoagulation Strategies: Pre-, During, and Post-Catheter Ablation of AF

Preablation

During ablation

Postablation

Class of Recommendations and Level of Evidence

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology

Asymptomatic AF^a