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 DefinitionsHa...
Diagnosis
...agnosi...
...a. Indications for Catheter Ablation o...
...atheter ablation is recommended. (I, A)573...
...rsistent: Catheter ablation is reasonable. (IIa,...
...ng persistent: Catheter ablation may b...
...Catheter ablation is reasonable....
Persistent: Catheter ablation is reasonable. (II...
...tanding persistent: Catheter ablat...
...ications for Atrial Fibrillation Abla...
...ive heart failure...
...s reasonable to use similar indications...
...r patients (>75 years of age)...
...reasonable to use similar indications fo...
...trophic cardiomyopathy...
It is reasonable to use similar indications for...
...oung patient...
...nable to use similar indications for A...
...achy-brady syn...
It is reasonable to offer AF ablation as an...
...letes with A...
...nable to offer high-level athletes AF ablatio...
...xysmal: Catheter ablation may be considered in sel...
...: Catheter ablation may be considered in s...
...2c. Indications for Concomitant Open (such...
...xysmal: Surgical ablation is recommended....
...t: Surgical ablation is recommended. (I, B-NR)573...
...ersistent: Surgical ablation is recomm...
...gical ablation is recommended. (I, B-NR)573...
...ersistent: Surgical ablation is recomm...
...ng-standing persistent: Surgical a...
...dications for Concomitant Closed (...
...oxysmal: Surgical ablation is recommende...
...urgical ablation is recommended. (...
...nding persistent: Surgical ablation is recommended...
...ical ablation is reasonable. (IIa, B...
...ent: Surgical ablation is reasonable. (IIa, B-NR...
...rsistent: Surgical ablation is reas...
...e 2e. Indications for Stand-Alone...
...aroxysmal: Stand-alone surgical ablation can be...
...t: Stand-alone surgical ablation i...
...persistent: Stand-alone surgical abla...
...sonable to apply the indications fo...
Treatment
...atment...
...Atrial Fibrillation Ablation: Strategies, Techn...
...lation of the PVs is recommended during all A...
...of electrical isolation requires, at a minim...
...ing for PV reconnection for 20 minute...
...istration of adenosine 20 minutes follo...
Use of a pace-capture (pacing along th...
...nstration of exit block may be consi...
...tient has a history of typical atrial...
...r ablation lesions are applied, op...
...eproducible focal trigger that initiates AF is id...
...orming AF ablation with a force-sensing RF ablatio...
...r wall isolation might be considered for init...
...of high-dose isoproterenol to screen for and th...
...xcitation frequency (DF)-based ablat...
...of creating linear ablation lesions in the...
...s of linear ablation lesions in the absence o...
...he usefulness of mapping and ablation of areas of...
...f ablation of complex fractionated atrial...
...he usefulness of ablation of rotational acti...
...s of ablation of autonomic ganglia as an initial...
Weight loss can be useful for patient...
...ble to consider a patient’s body mass...
...able to screen for signs and symptoms of sleep apn...
...sleep apnea can be useful for patients w...
...efulness of discontinuation of antiarrhyt...
...f initiation or continuation of antia...
...fication of the PV ostia is mandatory to avoid abl...
...recommended that RF power be reduced w...
...easonable to use an esophageal temperature prob...
...coagulation Strategies: Pre-, During, an...
...r patients undergoing AF catheter a...
...ergoing AF catheter ablation who have been...
...undergoing AF catheter ablation who h...
...ulation guidelines that pertain to ca...
...s anticoagulated with a NOAC prior to...
Performance of a transesophageal echocardio...
...formance of a TEE in patients who present for abl...
...se of intracardiac echocardiography to sc...
...hould be administered prior to or immediatel...
...on of protamine following AF catheter a...
...are not therapeutically anticoagulated prior to...
...oagulation with warfarin or a NOAC is recommend...
...herence to AF anticoagulation guidelines is reco...
...ecisions regarding continuation of sys...
...tients who have not been anticoagulated prior to...
...ents in whom discontinuation of antic...
...Signs and Symptoms Following AF AblationHaving tr...
...Types of Ambulatory Cardiac Monitoring D...
...le 7. Definitions of Complications Assoc...
...idence, Prevention, Diagnosis, and T...
.... Anatomical Drawings of the Heart Relevant...
.... Posterior Perspective of the Left Atrium and Pu...
...3. Schematic Drawing Showing Various...
...gure 4. Structure and Mechanisms of AF
...igure 5. Mechanisms of Atrial Flutter and Atr...
...e 6. Schematic of Common Lesion Sets Employed in...
...igure 7. Indications for Catheter...
...a. Indications for Surgical Ablation o...
...er Ablation of AF Using Either RF Energy or C...