Catheter and Surgical Ablation of Atrial Fibrillation

Paroxysmal: Catheter ablation is recommended. (I, A)

Persistent: Catheter ablation is reasonable. (IIa, B-NR)

Long-standing persistent: Catheter ablation may be considered. (IIb, C-LD)

Paroxysmal: Catheter ablation is reasonable. (IIa, B-R)

Persistent: Catheter ablation is reasonable. (IIa, C-EO)

Long-standing persistent: Catheter ablation may be considered. (IIb, C-EO)

Electrical isolation of the PVs is recommended during all AF ablation procedures. (I, A)

Achievement of electrical isolation requires, at a minimum, assessment and demonstration of entrance block into the PV. (I, B-R)

Monitoring for PV reconnection for 20 minutes following initial PV isolation is reasonable. (IIa, B-R)

Administration of adenosine 20 minutes following initial PV isolation using RF energy with reablation if PV reconnection may be considered. (IIb, B-R)

Use of a pace-capture (pacing along the ablation line) ablation strategy may be considered. (IIb, B-R)

Demonstration of exit block may be considered. (IIb, B-NR)

If the patient has a history of typical atrial flutter or typical atrial flutter is induced at the time of AF ablation, delivery of a cavotricuspid isthmus linear lesion is recommended. (I, B-R)

If linear ablation lesions are applied, operators should use mapping and pacing maneuvers to assess for line completeness. (I, C-LD)

If a reproducible focal trigger that initiates AF is identified outside the PV ostia at the time of an AF ablation procedure, ablation of the focal trigger should be considered. (IIa, C-LD)

When performing AF ablation with a force-sensing RF ablation catheter, a minimal targeted contact force of 5–10 grams is reasonable. (IIa, C-LD)

Posterior wall isolation might be considered for initial or repeat ablation of persistent or long-standing persistent AF. (IIb, C-LD)

Administration of high-dose isoproterenol to screen for and then ablate non-PV triggers may be considered during initial or repeat AF ablation procedures in patients with paroxysmal, persistent, or long-standing persistent AF. (IIb, C-LD)

Dominant excitation frequency (DF)-based ablation strategy is of unknown usefulness for AF ablation. (IIb, C-LD)

The usefulness of creating linear ablation lesions in the right or left atrium as an initial or repeat ablation strategy for persistent or long-standing persistent AF is not well established. (IIb, B-NR)

The usefulness of linear ablation lesions in the absence of macroreentrant atrial flutter is not well established. (IIb, C-LD)

The usefulness of mapping and ablation of areas of abnormal myocardial tissue identified with voltage mapping or MR imaging as an initial or repeat ablation strategy for persistent or long standing persistent AF is not well established. (IIb, B-R)

The usefulness of ablation of complex fractionated atrial electrograms as an initial or repeat ablation strategy for persistent and long- standing persistent AF is not well established. (IIb, B-R)

The usefulness of ablation of rotational activity as an initial or repeat ablation strategy for persistent and long-standing persistent AF is not well established. (IIb, B-NR)

The usefulness of ablation of autonomic ganglia as an initial or repeat ablation strategy for paroxysmal, persistent, and long-standing persistent AF is not well established. (IIb, B-NR)

Weight loss can be useful for patients with AF, including those who are being evaluated to undergo an AF ablation procedure, as part of a comprehensive risk factor management strategy. (IIa, B-R)

It is reasonable to consider a patient’s body mass index (BMI) when discussing the risks, benefits, and outcomes of AF ablation with a patient being evaluated for an AF ablation procedure. (IIa, B-R)

It is reasonable to screen for signs and symptoms of sleep apnea when evaluating a patient for an AF ablation procedure and recommend a sleep evaluation if sleep apnea is suspected. (IIa, B-R)

Treatment of sleep apnea can be useful for patients with AF, including those who are being evaluated to undergo an AF ablation procedure. (IIa, B-R)

The usefulness of discontinuation of antiarrhythmic drug therapy prior to AF ablation in an effort to improve long-term outcomes is unclear. (IIb, C-LD)

The usefulness of initiation or continuation of antiarrhythmic drug therapy during the post ablation healing phase in an effort to improve long-term outcomes is unclear. (IIb, C-LD)

Careful identification of the PV ostia is mandatory to avoid ablation within the PVs. (I, B-NR)

It is recommended that RF power be reduced when creating lesions along the posterior wall near the esophagus. (I, C-LD)

It is reasonable to use an esophageal temperature probe during AF ablation procedures to monitor esophageal temperature and help guide energy delivery. (IIa, C-EO)