Catheter and Surgical Ablation of Atrial Fibrillation
Key Points
Key Points
- Catheter and surgical ablation of atrial fibrillation (AF) are well established and important treatment options for patients with atrial fibrillation in whom a rhythm control strategy is chosen.
- A decision to perform catheter or surgical ablation of AF should be made after a careful consideration of the efficacy, risks, and alternatives to undergoing the ablation procedure. Patient preferences and values are important consideration. This document provides indications for both catheter and surgical AF ablation.
- The primary indication for performance of AF ablation is the presence of symptoms associated with atrial fibrillation. AF ablation is generally considered after at least one antiarrhythmic medication has been tried and proven to be ineffective or poorly tolerated.
- A desire to stop anticoagulation is not an appropriate indication for AF ablation. For most patients with AF who have a high stroke risk profile, anticoagulation should be continued following their ablation procedure.
- Catheter ablation of AF is associated with a risk of complications including development of a stroke or transient ischemic attack. Careful attention to anticoagulation prior to, during, and following the ablation procedure minimizes these risks.
- Multiple tools and strategies are available to perform both catheter and surgical ablation of AF. This document provides a detailed review of each of the available options and recommendations are made.
- There is considerable effort focused on developing new tools and techniques for AF ablation. This document contained recommendations concerning the performance of future clinical trials.
Table 1. Atrial Fibrillation Definitions
...1. Atrial Fibrillation Definitions...
Diagnosis
...Diagnosis
...Table 2a. Ind...
Paroxysmal: Catheter ablation is recommended. (...
...stent: Catheter ablation is reasonable. (IIa, B-N...
...persistent: Catheter ablation may be...
...smal: Catheter ablation is reasonable. (IIa, B-R)...
...istent: Catheter ablation is reasonable. (IIa...
...standing persistent: Catheter ablation...
...Table 2b. Indications for At...
...Conges...
...to use similar indications for AF ablation in s...
...Older patients (>75 years...
...sonable to use similar indications...
...Hypertrophic...
...reasonable to use similar indications for A...
...Young patients (...
...s reasonable to use similar indication...
...Tachy...
...t is reasonable to offer AF ablation a...
...Athletes with AF...
...e to offer high-level athletes AF ab...
...eter ablation may be considered in select patien...
...ent: Catheter ablation may be consi...
...Table 2c. Indications...
...al: Surgical ablation is recommended. (I, B-NR)5...
...tent: Surgical ablation is recommended. (I, B-NR...
...ersistent: Surgical ablation is recommended. (I,...
...roxysmal: Surgical ablation is recommended. (I...
...nt: Surgical ablation is recommended. (I, B-...
...ersistent: Surgical ablation is recommended. (I, B...
...Ta...
...xysmal: Surgical ablation is recommended. (I, B-...
...sistent: Surgical ablation is recommended....
...nding persistent: Surgical ablation i...
...mal: Surgical ablation is reasonable....
...ersistent: Surgical ablation is reas...
...-standing persistent: Surgical ablation is rea...
...smal: Stand-alone surgical ablation can be consi...
...and-alone surgical ablation is reasonable...
...g-standing persistent: Stand-alone sur...
...may be reasonable to apply the indications f...
Treatment
...Treatment...
...Table 3. Atr...
...isolation of the PVs is recommended...
...electrical isolation requires, at a...
...g for PV reconnection for 20 minutes follo...
...stration of adenosine 20 minutes following...
...capture (pacing along the ablation line) abla...
...ration of exit block may be considered....
...has a history of typical atrial f...
...f linear ablation lesions are applied,...
If a reproducible focal trigger that...
...en performing AF ablation with a force...
...wall isolation might be considered for init...
...nistration of high-dose isoproterenol to screen f...
...nt excitation frequency (DF)-based ablation stra...
...e usefulness of creating linear abl...
...sefulness of linear ablation lesions in th...
The usefulness of mapping and ablati...
...efulness of ablation of complex fractionated a...
...fulness of ablation of rotational activ...
...lness of ablation of autonomic ganglia as...
...be useful for patients with AF, including...
...is reasonable to consider a patient’s b...
...le to screen for signs and symptoms of sleep...
...ent of sleep apnea can be useful for pat...
...ess of discontinuation of antiarrhythmic dr...
...e usefulness of initiation or continuati...
...identification of the PV ostia is mandatory...
...recommended that RF power be reduced wh...
...is reasonable to use an esophageal te...
...Tabl...
...atients undergoing AF catheter abla...
...tients undergoing AF catheter ablation who h...
...ndergoing AF catheter ablation who have b...
...ation guidelines that pertain to ca...
...s anticoagulated with a NOAC prior to AF ca...
Performance of a transesophageal echocardi...
...e of a TEE in patients who present for ablatio...
...of intracardiac echocardiography to s...
...parin should be administered prior to or immed...
...ministration of protamine following...
...are not therapeutically anticoagu...
...stemic anticoagulation with warfarin or a N...
...erence to AF anticoagulation guideli...
...ons regarding continuation of systemic anti...
...who have not been anticoagulated prior to cat...
...om discontinuation of anticoagulation is being...
...gns and Symptoms Following AF Ablation...
...6. Types of Ambulatory Cardiac Mon...
Table 7. Definitions of Complications Associ...
...cidence, Prevention, Diagnosis, and Treatment of...
...Anatomical Drawings of the Heart Relevant to...
...igure 2. Posterior Perspective of the Left Atrium...
.... Schematic Drawing Showing Various Hypotheses a...
...ure and Mechanisms of AF Structure and mechanisms...
.... Mechanisms of Atrial Flutter and...
...6. Schematic of Common Lesion Sets Employe...
...gure 7. Indications for Catheter Ablation of Symp...
...ure 8a. Indications for Surgical Ablation...
...er Ablation of AF Using Either RF Energy or C...