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
Table 1. Atrial Fibrillation DefinitionsHavi...
Diagnosis
...iagnosis...
...ndications for Catheter Ablation of Atrial Fibr...
...Catheter ablation is recommended. (I, A)57...
...ersistent: Catheter ablation is reasonable. (IIa,...
...nding persistent: Catheter ablation may be cons...
...aroxysmal: Catheter ablation is reasonab...
...nt: Catheter ablation is reasonable. (IIa, C-EO...
...rsistent: Catheter ablation may be considered. (I...
...Indications for Atrial Fibrillation Ablation i...
...ngestive heart fai...
It is reasonable to use similar indic...
...patients (>75 years of...
...to use similar indications for AF ab...
...hic cardiomyopathy...
...able to use similar indications for AF...
...oung patients (
...e to use similar indications for AF ablation in yo...
...-brady syndrome...
...asonable to offer AF ablation as an alternative t...
...etes with AF...
...t is reasonable to offer high-level athletes AF...
...xysmal: Catheter ablation may be c...
...: Catheter ablation may be consider...
...c. Indications for Concomitant Open (such a...
Paroxysmal: Surgical ablation is recomm...
...rsistent: Surgical ablation is recommended....
...ding persistent: Surgical ablation is recomme...
...mal: Surgical ablation is recommended. (I, B-NR...
...gical ablation is recommended. (I, B-NR)573...
...persistent: Surgical ablation is recommen...
...ble 2d. Indications for Concomitant Cl...
...Surgical ablation is recommended. (I, B...
...t: Surgical ablation is recommended. (I, B-...
...g persistent: Surgical ablation is...
...Surgical ablation is reasonable. (IIa,...
...nt: Surgical ablation is reasonable. (IIa, B...
...rsistent: Surgical ablation is reasona...
...ations for Stand-Alone and Hybrid Sur...
...oxysmal: Stand-alone surgical ablation...
...t: Stand-alone surgical ablation is rea...
...ing persistent: Stand-alone surgical ablatio...
...ay be reasonable to apply the indi...
Treatment
...eatment...
Table 3. Atrial Fibrillation Ablation: Strategie...
...olation of the PVs is recommended during al...
...of electrical isolation requires, at a mi...
Monitoring for PV reconnection for 20 minutes...
...ation of adenosine 20 minutes followi...
...pture (pacing along the ablation li...
...onstration of exit block may be considered. (IIb...
...f the patient has a history of typical a...
...ear ablation lesions are applied, operators...
...reproducible focal trigger that initiates AF is...
...ming AF ablation with a force-sensing RF...
...sterior wall isolation might be considered...
...ation of high-dose isoproterenol to scr...
...inant excitation frequency (DF)-based ablation str...
...ulness of creating linear ablation les...
The usefulness of linear ablation lesions in the...
...e usefulness of mapping and ablation of areas of...
...sefulness of ablation of complex fra...
...fulness of ablation of rotational activity as a...
...lness of ablation of autonomic ganglia a...
...can be useful for patients with AF, inclu...
...to consider a patient’s body mass index (B...
...sonable to screen for signs and symptoms of...
...f sleep apnea can be useful for pat...
...fulness of discontinuation of antiarrhyt...
The usefulness of initiation or continu...
...ntification of the PV ostia is mandatory to avoi...
...nded that RF power be reduced when crea...
...sonable to use an esophageal temperature probe...
Table 4. Anticoagulation Strategies...
...undergoing AF catheter ablation wh...
...ents undergoing AF catheter ablation who h...
...ergoing AF catheter ablation who hav...
...ation guidelines that pertain to cardiover...
For patients anticoagulated with a NOAC pri...
...formance of a transesophageal echocardiogram (TE...
...rmance of a TEE in patients who present for abla...
...e of intracardiac echocardiography to screen for...
...ould be administered prior to or immedi...
...stration of protamine following AF catheter ab...
...are not therapeutically anticoagulated prior...
...mic anticoagulation with warfarin or a NOAC is re...
...o AF anticoagulation guidelines is recomm...
...garding continuation of systemic anticoagulation...
...tients who have not been anticoagulated pr...
...om discontinuation of anticoagulation is being co...
...and Symptoms Following AF AblationHaving tr...
...6. Types of Ambulatory Cardiac Monitoring DevicesH...
...7. Definitions of Complications Assoc...
...able 8. Incidence, Prevention, Diagnosis, and Tr...
...re 1. Anatomical Drawings of the Heart Releva...
...Posterior Perspective of the Left Atrium and...
...tic Drawing Showing Various Hypotheses and Prop...
...Structure and Mechanisms of AF...
...hanisms of Atrial Flutter and Atrial Tachycardia...
...hematic of Common Lesion Sets Employed in AF A...
...ations for Catheter Ablation of Symptomatic A...
...8. Indications for Surgical Ablation of AF — C...
...Catheter Ablation of AF Using Either RF...