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
.... Atrial Fibrillation DefinitionsHaving trouble vi...
Diagnosis
...iagnosi...
...a. Indications for Catheter Ablati...
...roxysmal: Catheter ablation is recommend...
...rsistent: Catheter ablation is reasonabl...
...anding persistent: Catheter ablation may b...
...ysmal: Catheter ablation is reasonable....
...atheter ablation is reasonable. (IIa,...
...ding persistent: Catheter ablation...
...b. Indications for Atrial Fibrillati...
...tive heart failu...
...le to use similar indications for AF ablati...
...patients (>75 years of age)...
...able to use similar indications for AF a...
...ertrophic cardiomyopath...
...to use similar indications for AF ablati...
...patients (...
...reasonable to use similar indications for...
Tachy-brady synd...
...to offer AF ablation as an alternative to pac...
...letes with...
...sonable to offer high-level athletes AF ablation a...
...ysmal: Catheter ablation may be consi...
...Catheter ablation may be considered...
...cations for Concomitant Open (such as Mitral...
...mal: Surgical ablation is recommended....
...rsistent: Surgical ablation is recommended. (I, B-...
...ding persistent: Surgical ablation is recomm...
...ysmal: Surgical ablation is recommend...
...tent: Surgical ablation is recommended. (I, B-NR)...
...g-standing persistent: Surgical ablation is re...
...e 2d. Indications for Concomitant Closed (suc...
...Surgical ablation is recommended. (I, B-N...
...ical ablation is recommended. (I, B-NR)573...
...rsistent: Surgical ablation is recommended....
...ical ablation is reasonable. (IIa, B-NR)...
...ical ablation is reasonable. (IIa, B-NR)573...
...ersistent: Surgical ablation is reasona...
...Indications for Stand-Alone and Hybrid Surgical...
...nd-alone surgical ablation can be considered fo...
...tent: Stand-alone surgical ablation is r...
...ersistent: Stand-alone surgical ablation is reas...
...asonable to apply the indications f...
Treatment
...atment...
...al Fibrillation Ablation: Strategies, Techniq...
...rical isolation of the PVs is recommen...
...of electrical isolation requires, at a minim...
...PV reconnection for 20 minutes following ini...
Administration of adenosine 20 minute...
...pture (pacing along the ablation line) a...
...of exit block may be considered. (IIb, B-NR)57...
...as a history of typical atrial flutt...
...linear ablation lesions are applied, operators s...
...ible focal trigger that initiates AF is identif...
...hen performing AF ablation with a force-sensing...
...terior wall isolation might be considered for init...
...nistration of high-dose isoproterenol to scree...
...nant excitation frequency (DF)-based ablation str...
...ness of creating linear ablation lesions...
...lness of linear ablation lesions in the abs...
...e usefulness of mapping and ablation of areas of...
...s of ablation of complex fractionated atrial el...
...e usefulness of ablation of rotational activity...
...fulness of ablation of autonomic gang...
...oss can be useful for patients with AF,...
It is reasonable to consider a patient...
...sonable to screen for signs and symptoms of sl...
...of sleep apnea can be useful for pati...
The usefulness of discontinuation of anti...
...ss of initiation or continuation of antiarrhythm...
...identification of the PV ostia is manda...
...ed that RF power be reduced when c...
It is reasonable to use an esophageal temperatur...
...able 4. Anticoagulation Strategies...
...undergoing AF catheter ablation who...
...dergoing AF catheter ablation who have been...
...s undergoing AF catheter ablation who hav...
...ation guidelines that pertain to cardioversio...
For patients anticoagulated with a NOAC p...
...rmance of a transesophageal echocardiogram...
...a TEE in patients who present for abla...
...cardiac echocardiography to screen for atria...
...in should be administered prior to...
Administration of protamine following AF cathe...
...nts who are not therapeutically anticoag...
...anticoagulation with warfarin or a NOAC is rec...
...herence to AF anticoagulation guidelin...
...ons regarding continuation of systemic a...
...who have not been anticoagulated prior to cath...
...n whom discontinuation of anticoagulatio...
...le 5. Signs and Symptoms Following AF Ablatio...
...pes of Ambulatory Cardiac Monitoring...
...ble 7. Definitions of Complication...
...ble 8. Incidence, Prevention, Diagnosis, an...
...natomical Drawings of the Heart Relevant to AF A...
...gure 2. Posterior Perspective of the Left...
...gure 3. Schematic Drawing Showing Various Hyp...
...ure 4. Structure and Mechanisms of AF...
...igure 5. Mechanisms of Atrial Flutter and A...
...ure 6. Schematic of Common Lesion Sets Employ...
...Indications for Catheter Ablation of Sy...
...ations for Surgical Ablation of AF —...
...9. Catheter Ablation of AF Using Either RF Energ...