Catheter and Surgical Ablation of Atrial Fibrillation

Publication Date: April 8, 2024

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 Ablation of Atri...

...mal: Catheter ablation is recommended....

...heter ablation is reasonable. (IIa, B-NR)573...

...ng persistent: Catheter ablation may be consi...

...mal: Catheter ablation is reasonable. (IIa, B-R)5...

...istent: Catheter ablation is reasonable. (IIa,...

...standing persistent: Catheter ablation...


...Indications for Atrial Fibrillation Ablation i...

...ive heart failure...

...t is reasonable to use similar indications for AF...

...nts (>75 years of age)...

It is reasonable to use similar indications for AF...

...phic cardiomyopathy...

...le to use similar indications for AF a...

...ng patients (

...reasonable to use similar indications for AF...

Tachy-brady sy...

...t is reasonable to offer AF ablation...

...etes with AF

...is reasonable to offer high-level athletes AF...

...smal: Catheter ablation may be considered...

...t: Catheter ablation may be considered in sele...


...ble 2c. Indications for Concomitant O...

...ysmal: Surgical ablation is recomm...

...istent: Surgical ablation is recommen...

...ng persistent: Surgical ablation is recommended....

...l: Surgical ablation is recommended. (I, B-NR)573...

...ent: Surgical ablation is recommended. (I, B-NR)...

...ersistent: Surgical ablation is recommended. (I...


...tions for Concomitant Closed (such as CABG and...

Paroxysmal: Surgical ablation is reco...

...rsistent: Surgical ablation is recommended. (...

...persistent: Surgical ablation is recommended. (I,...

...roxysmal: Surgical ablation is reasona...

...istent: Surgical ablation is reasonable....

...standing persistent: Surgical ablation is...


...ations for Stand-Alone and Hybrid Surgical Ab...

...oxysmal: Stand-alone surgical ablation ca...

...t: Stand-alone surgical ablation is reasonable f...

...rsistent: Stand-alone surgical ablation is reasona...

...reasonable to apply the indications for st...


Treatment

Treatmen...

...3. Atrial Fibrillation Ablation: Stra...

...lectrical isolation of the PVs is recommended du...

...f electrical isolation requires, at a minimum,...

...nitoring for PV reconnection for 20 mi...

...of adenosine 20 minutes following in...

Use of a pace-capture (pacing along the ablatio...

...on of exit block may be considered....

...the patient has a history of typical at...

...lation lesions are applied, operators should u...

...eproducible focal trigger that initiates A...

...n performing AF ablation with a force-sensing...

...solation might be considered for initial or...

...ministration of high-dose isoprote...

...ation frequency (DF)-based ablation s...

...he usefulness of creating linear ablation lesi...

...ss of linear ablation lesions in the abse...

...fulness of mapping and ablation of area...

...e usefulness of ablation of complex fraction...

...lness of ablation of rotational activity...

...ess of ablation of autonomic ganglia...

...n be useful for patients with AF, in...

...nable to consider a patient’s body mas...

...reasonable to screen for signs and symptom...

...ep apnea can be useful for patients...

...e usefulness of discontinuation of antiarr...

...sefulness of initiation or continuatio...

...identification of the PV ostia is mandatory to a...

...is recommended that RF power be reduced...

...reasonable to use an esophageal te...


...Anticoagulation Strategies: Pre-,...

...atients undergoing AF catheter ablation...

...ergoing AF catheter ablation who ha...

...ients undergoing AF catheter ablation who ha...

...ation guidelines that pertain to card...

...ents anticoagulated with a NOAC prior to...

...f a transesophageal echocardiogram (TE...

...mance of a TEE in patients who present...

...tracardiac echocardiography to screen for a...

...ld be administered prior to or immediately followi...

...ion of protamine following AF catheter abl...

...are not therapeutically anticoagulated...

...oagulation with warfarin or a NOAC i...

...ence to AF anticoagulation guidelines is...

...sions regarding continuation of systemic antico...

...ho have not been anticoagulated prior to catheter...

...ts in whom discontinuation of anticoagulation...


...and Symptoms Following AF AblationHaving trou...


...s of Ambulatory Cardiac Monitoring DevicesHavin...


...ble 7. Definitions of Complications Associated...


.... Incidence, Prevention, Diagnosis, and Treatme...


...Anatomical Drawings of the Heart Relevant to AF...


...Posterior Perspective of the Left Atri...


...atic Drawing Showing Various Hypotheses and Propos...


...ure 4. Structure and Mechanisms of AF...


...anisms of Atrial Flutter and Atrial Tachycardia...


...e 6. Schematic of Common Lesion Sets Emp...


...igure 7. Indications for Catheter A...


...dications for Surgical Ablation of AF — Concomi...


...gure 9. Catheter Ablation of AF Using Either R...