Atrial Fibrillation Ablation: Techniques, Benefits, Risks

Posted on Feb 9, 2025 in Agriculture

Updated 2016 Nov 08 12:00 AM (ET)
Antiarrhythmic drugs may reduce atrial fibrillation-related events while on therapy (up to 90 days), but benefit may not persist after therapy is discontinued (up to 1 year) (Eur Heart J 2016 Feb 14) view update
Cryoballoon ablation is as effective as radiofrequency ablation for treatment of symptomatic paroxysmal atrial fibrillation refractory to antiarrhythmic drugs or beta blockers (N Engl J Med 2016 Jun) view update
Catheter ablation may reduce recurrence and mortality compared to amiodarone in adults with persistent atrial fibrillation, heart failure, and device implantation (Circulation 2016 Apr 26) view update

Overview and Recommendations

Background

Ablation therapy involves the placement of circumferential lesions within the atria and/or conduction system to manage symptomatic patients with atrial fibrillation (AF).
- It can be performed by a catheter, surgery, or both.
- It may provide the most benefit to patients with symptomatic paroxysmal AF without apparent structural heart disease.
Ablation of AF may be superior to antiarrhythmic drug therapy and/or used as first-line therapy for maintenance of normal sinus rhythm (NSR) in selected patients.
Ablation of the atrioventricular (AV) node and placement of a permanent pacemaker may be considered in selected, symptomatic patients with AF when the rate cannot be adequately controlled with medications.

Evaluation

Assess procedural risks and possible outcomes for patients with atrial fibrillation (AF) prior to ablation (Strong recommendation).
Consider ablation therapy for AF based upon a number of factors including:
- Type of AF (paroxysmal versus persistent versus longstanding persistent)
- Degree of symptoms
- Presence of structural heart disease
- Whether or not patients who are candidates for more standard rate or rhythm control approaches have been given an adequate trial and failed
- Likelihood of complications
- Patient preferences

Management

Catheter Ablation

Offer catheter ablation to patients with (Strong recommendation):
- Symptomatic paroxysmal atrial fibrillation (AF) who have failed treatment with antiarrhythmic drugs who also have:
  - A normal or mildly dilated left atrium, normal or mildly reduced left ventricular function, and the absence of severe pulmonary disease
- Symptomatic AF and Wolff-Parkinson-White (WPW) preexcitation syndrome
Consider catheter ablation in patients with (Weak recommendation):
- Symptomatic paroxysmal or persistent AF prior to a trial of antiarrhythmic drug
- Symptomatic paroxysmal AF who have failed antiarrhythmic drug treatment and have significant left atrial dilatation or left ventricular dysfunction
- Symptomatic persistent or longstanding persistent AF who have failed antiarrhythmic drugs
- Symptomatic longstanding persistent AF

Medications After Catheter Ablation

Anticoagulation should continue for at least 3 months after catheter ablation.
Consider continuing anticoagulation beyond this period based on risk of thromboembolism (Weak recommendation).
Consider prescribing proton-pump inhibitors for up to 4 weeks to reduce risk of atrio-esophageal fistula.
Consider antiarrhythmic drug therapy for 6 weeks to 3 months to reduce the incidence of atrial fibrillation-related adverse events.

Surgical Ablation

Consider stand-alone surgical ablation of patients with symptomatic paroxysmal, persistent, or longstanding persistent AF refractory or intolerant to at least 1 class I or class III antiarrhythmic medication, including those
- Who have failed ≥ 1 attempts at catheter ablation
- Who have not failed catheter ablation but prefer a surgical approach
Consider surgical ablation for treatment of AF in patients who are having cardiac surgery for other reasons with (Weak recommendation):
- Paroxysmal, persistent, or longstanding persistent AF refractory or intolerant to at least 1 class I or class III antiarrhythmic medication
- Paroxysmal or persistent AF prior to starting antiarrhythmic drug therapy
“Hybrid” or “Convergent” procedures including minimally invasive surgery and catheter ablation are being evaluated

AV Nodal Catheter Ablation

Do not perform atrioventricular (AV) node ablation unless a previous trial of medical therapy has failed to adequately control heart rate (Strong recommendation).
Consider AV node ablation in combination with permanent pacemaker placement for patients (Weak recommendation):
- With AF if rate control with drugs is ineffective or not tolerated
- With heart failure and permanent AF if there are indications for cardiac resynchronization therapy

Catheter Ablation of Accessory Pathway in Patients with Wolff-Parkinson-White Syndrome

In patients with Wolff-Parkinson-White syndrome:
- Perform immediate catheter ablation of accessory pathway in those who are survivors of sudden cardiac death (Strong recommendation).
- Perform catheter ablation of an overt accessory pathway to prevent sudden cardiac death in those who also have AF (Strong recommendation).
- Perform catheter ablation of an overt accessory pathway for patients who are asymptomatic but have a high-risk profession, such as pilot or public transport driver (Strong recommendation).

Related Summaries

Overview

Catheter ablation
- Potential indications
  - Symptomatic paroxysmal atrial fibrillation in patients who failed antiarrhythmic drug and have no structural heart disease (HRS/EHRA/ECAS Class I, Level A; ACC/AHA Class I, Level A; ESC Class I, Level A; CCS Strong recommendation, Moderate-quality evidence)
  - Symptomatic paroxysmal atrial fibrillation in patients who failed antiarrhythmic drug and have significant left atrial dilatation or left ventricular dysfunction (ACC/AHA Class IIb, Level A; CCS Conditional recommendation, Moderate-quality evidence)
  - Symptomatic persistent atrial fibrillation in patients who failed antiarrhythmic drugs (HRS/EHRA/ECAS Class IIa, Level B; ACC/AHA Class IIa, Level A; ESC Class IIa, Level B; CCS Strong recommendation, Moderate-quality evidence)
  - Symptomatic longstanding persistent atrial fibrillation in patients who failed antiarrhythmic drugs (HRS/EHRA/ECAS Class IIb, Level B; ESC Class IIb, Level C; CCS Strong recommendation, Moderate-quality evidence)
  - Symptomatic paroxysmal atrial fibrillation prior to trial of antiarrhythmic drug (HRS/EHRA/ECAS Class IIa, Level B; ESC Class IIb, Level B; CCS Conditional recommendation, Low-quality evidence)
  - Symptomatic persistent atrial fibrillation prior to trial of antiarrhythmic drug (HRS/EHRA/ECAS Class IIb, Level C)
- Efficacy compared to drug therapy
  - Catheter ablation may reduce recurrence of atrial fibrillation compared with medical treatment in patients with paroxysmal or persistent atrial fibrillation, but evidence inadequate to identify best technique (level 3 [lacking direct] evidence)
  - Radiofrequency catheter ablation after failed drug therapy may maintain sinus rhythm, improve quality of life, and reduce hospital readmission rates more than continued drug therapy (level 2 [mid-level] evidence)
  - Radiofrequency catheter ablation may reduce symptomatic atrial fibrillation compared to antiarrhythmic drug therapy in patients with paroxysmal atrial fibrillation without previous treatment with antiarrhythmic drugs (level 2 [mid-level] evidence)
  - In patients with heart failure
    - Radiofrequency catheter ablation might improve exercise performance and quality of life compared to rate control therapy in adults with persistent atrial fibrillation and heart failure (level 2 [mid-level] evidence)
    - Pulmonary vein isolation associated with improved quality of life compared to atrioventricular node ablation with biventricular pacing in patients with drug-refractory atrial fibrillation and heart failure (level 2 [mid-level] evidence)
- Medications after ablation
  - Antithrombotic therapy recommendations similar to recommendations after cardioversion, except continuing anticoagulation for at least 2-3 months after ablation recommended
  - Corticosteroids for 3 days after radiofrequency catheter ablation may decrease immediate and long-term atrial fibrillation recurrence (level 2 [mid-level] evidence)
  - Antiarrhythmic drug for 6 weeks may reduce incidence of atrial fibrillation-related adverse events at 6 weeks (level 2 [mid-level] evidence) but not at 6 months (level 3 [lacking direct] evidence) following ablative therapy
Surgical ablation
- In patients having cardiac surgery for other reasons, consider concomitant surgical ablation for symptomatic atrial fibrillation (HRS/EHRA/ECAS Class IIa, Level C; ESC Class IIa, Level A; CCS Strong recommendation, Moderate-quality evidence) and possibly for asymptomatic atrial fibrillation (ESC Class IIb, Level C)
- In patients not having concomitant cardiac surgery, minimally invasive surgical ablation may be done for symptomatic atrial fibrillation after failure of catheter ablation (ESC Class IIb, Level C; HRS/EHRA/ECAS Class IIb, Level C) or in patients who prefer a surgical approach (HRS/EHRA/ECAS Class IIb, Level C)
- Surgical ablation appears to increase freedom from atrial fibrillation, but does not appear to affect mortality (level 2 [mid-level] evidence)
- Surgical ablation may be as effective as radiofrequency-microwave or cryoablation for conversion to sinus rhythm in patients with atrial fibrillation (level 3 [lacking direct] evidence)
- Surgical ablation may be more effective than catheter ablation for reducing left atrial arrhythmia (level 3 [lacking direct] evidence) but associated with more procedural adverse events (level 2 [mid-level] evidence) in patients with atrial fibrillation refractory to antiarrhythmic drugs

Atrioventricular (AV) node ablation
- Should not be attempted unless a previous trial of medical therapy has failed to adequately control heart rate (ACC/AHA Class III, Level C; ESC Class III, Level C)
- May be considered for rate control if drugs are ineffective or not tolerated (ACC/AHA Class IIa, Level B; ESC Class IIa, Level B; CCS Strong recommendation, Moderate-quality evidence)
- In patients with heart failure and indications for cardiac resynchronization therapy
  - Consider AV node ablation for patients with permanent atrial fibrillation (ESC Class IIa, Level B)
  - Atrioventricular junction ablation may improve multiple outcomes (survival, hospitalization, surrogate outcomes) compared to pharmacologic rate control (level 2 [mid-level] evidence)

Ablation of accessory pathway in patients with Wolff-Parkinson-White syndrome
- Catheter ablation of accessory pathway recommended in symptomatic patients with evidence of ventricular preexcitation during atrial fibrillation, especially if syncope or pathway with short refractory period (ACC/AHA Class I, Level B; ESC Class I, Level A; CCS Strong recommendation, Low-quality evidence)
- Catheter ablation recommended for patients with asymptomatic overt accessory pathway conduction on surface electrocardiogram (ECG) if high-risk profession such as pilot or public transport driver (ESC Class I, Level B)

Definitions

First-diagnosed or first-time atrial fibrillation, often called new-onset atrial fibrillation, is when it is newly diagnosed in a patient, regardless of duration of atrial fibrillation or presence and severity of symptoms
Lone atrial fibrillation defined as atrial fibrillation in patients < 60 years old with no history or echocardiographic evidence of cardiovascular disease, hypertension, or CAD
Paroxysmal atrial fibrillation defined as
- Atrial fibrillation that terminates within 7 days of onset (usually < 48 hours) either spontaneously or with intervention
- May recur with variable frequency
Recurrent atrial fibrillation defined as ≥ 2 episodes of atrial fibrillation
Persistent atrial fibrillation defined as atrial fibrillation that is sustained > 7 days or requires termination by cardioversion
Longstanding persistent atrial fibrillation defined as atrial fibrillation persistent > 1 year with decision to adopt rhythm control strategy
Permanent atrial fibrillation refers to
- Joint decision by patient and clinician to stop additional attempts to restore or maintain normal sinus rhythm
- Reasonable for acceptance to change based on evolution of symptoms, efficacy of therapeutic interventions, and patient and clinician preferences
References – Circulation 2014 Dec 2;130(23):e199 full-text, also published in J Am Coll Cardiol 2014 Dec 2;64(21):e1 full-text, corrections can be found in Circulation 2014 Dec 2;130(23):e272 and J Am Coll Cardiol 2014 Dec 2;64(21):2305; Eur Heart J 2010 Oct;31(19):2369 full-text; Circulation 2006 Aug 15;114(7):e257 full-text

General Information

General Considerations

Ablation therapy by a catheter or surgery can be used to treat symptomatic patients with atrial fibrillation (AF)
Patients most likely to benefit are those with symptomatic paroxysmal AF without apparent structural heart disease⁽⁶⁾
Patient desire to eliminate the need for long-term anticoagulation by itself should not be considered an appropriate selection criterion⁽¹⁾
The decision to consider ablation therapy for AF depends upon a number of factors including⁽⁶⁾
- Type of AF (paroxysmal versus persistent versus longstanding persistent)
- Degree of symptoms
- Presence of structural heart disease
- Whether or not patients who are candidates for more standard rate or rhythm control approaches have been given an adequate trial and failed
- Likelihood of complications
- Patient preferences
Procedural complications include^(1, 3)
- Pulmonary vein stenosis
- Cardiac tamponade
- Atrial-esophageal fistula
- Thromboembolic stroke
- Vascular access site complications
- Phrenic nerve injury
- Gastroparesis
- Death

Rationale for Ablation Therapy

Long-term effectiveness of antiarrhythmic drugs for avoidance of initiation and perpetuation of atrial fibrillation appears limited⁽²⁾
Chronic administration of antiarrhythmic drugs is needed and may be associated with side effects limiting use⁽²⁾
Pulmonary veins are electrically active structures containing a variable distance of a sleeve of syncytial myocardium extending from the left atrium^(1, 3)
Placement of circumferential ablation lesions around pulmonary ostia
- Creates electrical isolation^(1, 2)
- May alter arrhythmogenic substrate by either or both of⁽¹⁾
  - Eliminating tissue near the atrial-pulmonary vein junction which may generate or perpetuate atrial fibrillation
  - Reducing atrial tissue mass needed to sustain reentry
  - Reduced parasympathetic atrial stimulation by ablation of ganglionated plexi

Types and Classification of Atrial Fibrillation (AF)

AF episode⁽¹⁾
- documented by electrocardiography (ECG) monitoring
- duration ≥ 30 seconds or present continuously throughout monitoring if
- presence of subsequent episodes of AF requires that sinus rhythm be documented by ECG monitoring between AF episodes
paroxysmal AF⁽¹⁾
- recurrent AF (≥ 2 episodes) terminating spontaneously within 7 days
- classify episodes ≥ 48 hours that are terminated with cardioversion (electric or pharmacologic) as paroxysmal AF episodes
persistent AF⁽¹⁾
- continuous AF > 7 days
- electrically or pharmacologically cardioverted episodes of AF after ≥ 48 hours but before 7 days
longstanding persistent AF – continuous AF for > 12 months⁽¹⁾
permanent AF⁽¹⁾
- sinus rhythm not restored or maintained by any means including catheter or surgical ablation
- patients with permanent AF not appropriate for catheter or surgical ablation of AF

Catheter Ablation

Recommendations

Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECAS)

for symptomatic AF refractory or intolerant to at least 1 class I or class III antiarrhythmic medication, catheter ablation⁽¹⁾
- recommended for paroxysmal AF (HRS/EHRA/ECAS Class I, Level A)
- reasonable for persistent AF (HRS/EHRA/ECAS Class IIa, Level B)
- may be considered for longstanding persistent AF (HRS/EHRA/ECAS Class IIb, Level B)
for symptomatic AF prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication, catheter ablation⁽¹⁾
- reasonable for paroxysmal AF (HRS/EHRA/ECAS Class IIa, Level B)
- may be considered for persistent AF or longstanding persistent AF (HRS/EHRA/ECAS Class IIb, Level C)

American College of Cardiology/American Heart Association (ACC/AHA)

assess procedural risks and possible outcomes for patient prior to catheter ablation (ACC/AHA Class I, Level C)⁽⁶⁾
catheter ablation of the accessory pathway recommended in symptomatic patients with atrial fibrillation with Wolff-Parkinson-White (WPW) preexcitation syndrome, particularly if the accessory pathway may permit rapid antegrade conduction due to a short refractory period (ACC/AHA Class I, Level C)⁽⁶⁾
catheter ablation in these recommendations refers to pulmonary vein isolation with catheter ablation performed in experienced centers (performing > 50 catheter ablation cases per year) unless otherwise noted⁽⁶⁾
- catheter ablation recommended for maintaining sinus rhythm in
  - selected patients with significantly symptomatic, paroxysmal atrial fibrillation who have all of (ACC/AHA Class I, Level A)
    - failed treatment with ≥ 1 class I or III antiarrhythmic drug
    - normal or mildly dilated left atria
    - normal or mildly reduced left ventricular function
    - no severe pulmonary disease
- catheter ablation reasonable to treat patients with
  - symptomatic persistent atrial fibrillation contraindicated to or symptomatic despite use of ≥ 1 class I or III antiarrhythmic medications (ACC/AHA Class IIa, Level A)
  - recurrent symptomatic paroxysmal atrial fibrillation as initial treatment prior to antiarrhythmic drug therapy (ACC/AHA Class IIa, Level B)
- catheter ablation may be considered to treat patients with
  - symptomatic paroxysmal atrial fibrillation with significant left atrial dilatation or with significant left ventricular dysfunction (ACC/AHA Class IIb, Level A)
  - symptomatic persistent atrial fibrillation prior to treatment with class I or III antiarrhythmic medications (ACC/AHA Class IIb, Level C)
- do not perform catheter ablation
  - in patients with contraindications to anticoagulation therapy (ACC/AHA Class III, Level C)
  - for the sole purpose of averting anticoagulation therapy (ACC/AHA Class III, Level C)
in patients with hypertrophic cardiomyopathy, catheter ablation may be a useful rhythm-control strategy when contraindicated to or symptomatic despite antiarrhythmic medications (ACC/AHA Class IIa, Level B)⁽⁶⁾

European Society of Cardiology (ESC)

catheter ablation of symptomatic paroxysmal atrial fibrillation is recommended in patients who have symptomatic recurrences of atrial fibrillation on antiarrhythmic drug therapy (amiodarone, dronedarone, flecainide, propafenone, sotalol) and who prefer further rhythm control therapy, when performed by electrophysiologist who has received appropriate training and is performing procedure in experienced center (ESC Class I, Level A)⁽⁵⁾
consider catheter ablation of atrial fibrillation as first-line therapy in selected patients with symptomatic paroxysmal atrial fibrillation as alternative to antiarrhythmic drug therapy, considering patient choice, benefit, and risk (ESC Class IIa, Level B)⁽⁵⁾
consider ablation of persistent symptomatic atrial fibrillation refractory to antiarrhythmic therapy (ESC Class IIa, Level B)⁽⁴⁾
catheter ablation of atrial fibrillation may be considered in⁽⁴⁾
- patients with heart failure when antiarrhythmic drugs (including amiodarone) fail to control symptoms (ESC Class IIb, Level B)
- patients with symptomatic longstanding persistent atrial fibrillation refractory to antiarrhythmic drugs (ESC Class IIb, Level C)
- prior to antiarrhythmic drugs in patients with symptomatic paroxysmal atrial fibrillation despite adequate rate control and no significant structural heart disease (ESC Class IIb, Level B)
ablation of common atrial flutter recommended as part of atrial fibrillation ablation procedure if documented before or during ablation procedure (ESC Class I, Level B)⁽⁴⁾
in patients with Wolff-Parkinson-White syndrome⁽⁴⁾
- catheter ablation of an overt accessory pathway recommended in patients with atrial fibrillation to prevent sudden cardiac death (ESC Class I, Level A)
- immediate referral for catheter ablation recommended in survivors of sudden cardiac death with overt accessory pathway conduction (ESC Class I, Level C)
- catheter ablation recommended for patients with asymptomatic overt accessory pathway conduction on surface electrocardiogram (ECG) if
  - high-risk profession such as pilot or public transport driver (ESC Class I, Level B)
  - high risk of developing atrial fibrillation (ESC Class I, Level B)
- consider catheter ablation in patients with asymptomatic overt accessory pathway conduction only after full explanation and careful counseling (ESC Class IIa, Level B)

Canadian Cardiovascular Society (CCS)

catheter ablation of atrial fibrillation recommended in patients who remain symptomatic following adequate trials of antiarrhythmic drug therapy and in whom rhythm control strategy remains desired (CCS Strong recommendation, Moderate-quality evidence)
curative catheter ablation recommended for symptomatic patients with typical atrial flutter (CCS Strong recommendation, Moderate-quality evidence)
catheter ablation of accessory pathway recommended in patients with evidence of ventricular preexcitation during atrial fibrillation, especially if atrial fibrillation associated with rapid ventricular rate, syncope, or pathway with short refractory period (CCS Strong recommendation, Low-quality evidence)
catheter ablation to maintain sinus rhythm suggested
- in select patients with symptomatic atrial fibrillation and mild to moderate structural heart disease who are refractory to or intolerant of ≥ 1 antiarrhythmic drugs (CCS Conditional recommendation, Moderate-quality evidence)
- as first-line therapy for symptom relief in highly selected patients with symptomatic, paroxysmal atrial fibrillation (CCS Conditional recommendation, Low-quality evidence)
- to be performed by expert electrophysiologists with high annual procedural volume (CCS Conditional recommendation, Low-quality evidence)
in young patients with lone paroxysmal atrial fibrillation, electrophysiological study suggested to exclude reentrant tachycardia as cause of atrial fibrillation (and curative ablation suggested if present) (CCS Conditional recommendation, Very Low-quality evidence)
References – Can J Cardiol 2011 Jan-Feb;27(1):60, Can J Cardiol 2014 Oct;30(10):1114

National Institute of Health and Care Excellence (NICE)

left atrial catheter ablation
- recommended for patients with paroxysmal atrial fibrillation refractory to medications
- may be considered for patients with persistent atrial fibrillation refractory to medications
- consider before pacing and atrioventricular node ablation for patients with
  - paroxysmal atrial fibrillation
  - heart failure caused by paroxysmal or persistent atrial fibrillation
- discuss risk and benefits with patients prior to performing procedure
- Reference – NICE 2014 Jun:CG180 PDF

Efficacy

catheter ablation reported to be effective in short and long term (level 3 [lacking direct] evidence)
- based on systematic review of case series
- systematic review of 19 studies evaluating percutaneous catheter ablation outcomes at ≥ 3 years after index ablation procedure 6,167 patients with atrial fibrillation
- all studies had mean follow-up of ≥ 24 months
- freedom from atrial fibrillation
  - at 12 months with single-procedure
    - 64.2% (95% CI 33.8%-69.5%) overall in 19 studies with 6,167 patients, results limited by significant heterogeneity
    - 51.9% (95% CI 33.8%-69.5%) for non-paroxysmal atrial fibrillation, results limited by significant heterogeneity
    - 66.6% (95% CI 58.2%-74.2%) for paroxysmal atrial fibrillation, results limited by significant heterogeneity
  - at long-term follow-up with single-procedure
    - 53.1% (95% CI 46.2%-60%) overall, in 19 studies with 6,167 patients, results limited by significant heterogeneity
    - 41.8% (95% CI 25.2%-60.5%) for non-paroxysmal atrial fibrillation, results limited by significant heterogeneity
    - 54.1% (95% CI 44.4%-63.4%) for paroxysmal atrial fibrillation, results limited by significant heterogeneity
  - at long-term follow-up with multiple procedures
    - 79.8% overall (95% CI 75%-83.8%) in 13 studies, results limited by significant heterogeneity
    - 77.8% (95% CI 68.7%-84.9%) for non-paroxysmal atrial fibrillation, results limited by significant heterogeneity
    - 79% (95% CI 67.6%-87.1%) for paroxysmal atrial fibrillation, results limited by significant heterogeneity
- Reference – J Am Heart Assoc 2013 Mar 18;2(2):e004549 full-text
catheter ablation reported to increase ratio of asymptomatic to symptomatic atrial fibrillation episodes (level 3 [lacking direct] evidence)
- based on case series
- 50 patients with symptomatic atrial fibrillation having catheter ablation had insertion of implantable cardiac monitor (ICM) ≥ 3 months before ablation and ICM remained in place for ≥ 18 months after ablation
- 2,355 ICM episodes recorded (69% episodes deemed true atrial fibrillation/atrial flutter)
- 46% had elimination of symptomatic and asymptomatic recurrences of atrial fibrillation/atrial flutter/atrial tachycardia at 18 months
- ratio of asymptomatic to symptomatic atrial fibrillation episodes 1.1 before ablation vs. 3.7 after ablation (p = 0.002)
- comparing before vs. after ablation
  - atrial fibrillation burden 2 hours/day vs. 0.3 hours/day (p
  - median duration of atrial fibrillation episode 22 minutes vs. 6 minutes (p
  - asymptomatic status in 52% vs. 79% (p = 0.002)
- Reference – JAMA Intern Med 2013 Jan 28;173(2):149, editorial can be found in JAMA Intern Med 2013 Jan 28;173(2):156, and in JAMA Intern Med 2013 Jan 28;173(2):157

Efficacy compared to drug therapy

catheter ablation strategy with repeat interventions as necessary, rather than chronic antiarrhythmic drugs, may provide long-term benefits in terms of recurrent arrhythmia, complications, and quality of life⁽²⁾
catheter ablation may reduce recurrence of atrial fibrillation compared to medical treatment in patients with paroxysmal or persistent atrial fibrillation (level 2 [mid-level] evidence)
- based on Cochrane review of trials with methodologic limitations
- systematic review of 32 randomized trials evaluating catheter ablation in 3,560 patients with paroxysmal or persistent atrial fibrillation
  - 7 trials compared catheter ablation to medical therapies
  - 25 trials compared different catheter ablation methods
- all trials had ≥ 1 limitation including
  - unclear allocation concealment
  - lack of blinding
- comparing catheter ablation to medical therapies, catheter ablation associated with
  - reduced risk of recurrence of atrial fibrillation in analysis of 7 trials with 760 patients (all trials included in subsequent systematic review below)
    - risk ratio 0.27 (95% CI 0.18-0.41)
    - NNT 2-3 with recurrence of atrial fibrillation in 76% of medical therapies group
  - no significant differences in mortality, fatal or nonfatal embolic complications, and death from thromboembolic events
- Reference – Cochrane Database Syst Rev 2012 Apr 18;(4):CD007101

catheter ablation as first- or second-line therapy may reduce recurrence of atrial fibrillation but may increase major adverse events compared to antiarrhythmic drug therapy (level 2 [mid-level] evidence)
- based on systematic review without assessment of allocation concealment
- systematic review of 11 randomized trials comparing catheter ablation vs. antiarrhythmic drug as first- or second-line therapy for maintenance of sinus rhythm in 1,481 patients with atrial fibrillation
- catheter ablation associated with
  - reduced atrial tachyarrhythmia in analysis of 11 trials with 1,481 patients
    - risk ratio (RR) 0.4 (95% CI 0.31−0.52)
    - NNT 3-4 with atrial tachyarrhythmia in 65% of antiarrhythmic drug therapy group
    - benefits of catheter ablation both as first- and as second-line therapy reported in subgroup analyses
  - increased major adverse events in analysis of 11 trials with 1,468 patients
    - RR 2.04 (95% CI 1.1–3.77)
    - NNH 19-526 with major adverse events in 1.9% of antiarrhythmic drug therapy group
    - major adverse events included pulmonary vein stenosis, mortality, atrioesophageal fistula, life-threatening arrhythmia, hemorrhage, pericardial complications, and cardiovascular accident or transient ischemic attack
  - improvement in quality of life scores for physical and mental health domains of 36-item Short Form General Health Survey in 4 trials; 2 additional trials using different scales did not find significant differences between groups
- Reference – Circ Arrhythm Electrophysiol 2014 Oct;7(5):853

catheter ablation (alone or with medical therapy) may reduce recurrence of atrial fibrillation compared to medical therapy in patients with persistent atrial fibrillation (level 2 [mid-level] evidence)
- based on systematic review without assessment of allocation concealment
- systematic review of 32 randomized trials and 14 observational studies evaluating catheter ablation in 6,085 patients with atrial fibrillation
- 23 studies enrolled only patients with persistent atrial fibrillation, remaining studies enrolled mixed populations
- all analyses limited to patients with persistent atrial fibrillation
- catheter ablation (alone or with medical therapy) associated with reduced risk of recurrent atrial fibrillation compared to medical therapy alone in analysis of 4 trials with 547 patients
  - odds ratio 0.33 (95% CI 0.22-0.49)
  - NNT 3-6 with recurrent atrial fibrillation in 62% of medical therapy alone group
- Reference – Circ Arrhythm Electrophysiol 2014 Oct;7(5):841

radiofrequency catheter ablation may reduce symptomatic atrial fibrillation compared to antiarrhythmic drug therapy in patients with paroxysmal atrial fibrillation without previous treatment with antiarrhythmic drugs (level 2 [mid-level] evidence)
- based on 3 randomized trials without blinding of patients or with high crossover rate
  - 294 patients ≤ 70 years old with paroxysmal atrial fibrillation and no history of antiarrhythmic drug use were randomized to radiofrequency catheter ablation vs. antiarrhythmic drug therapy
    - patients were not blinded
    - antiarrhythmic drug therapy included class IC (flecainide 200 mg/day or propafenone 600 mg/day) or class III (amiodarone 200 mg/day or sotalol 160 mg/day)
    - at baseline all patients had ≥ 2 episodes of symptomatic atrial fibrillation within preceding 6 months but no episode of atrial fibrillation > 7 days (without spontaneous termination or cardioversion)
    - no significant differences in
      - cumulative burden of atrial fibrillation (percentage of time in atrial fibrillation on all Holter recordings obtained during follow-up)
      - burden of atrial fibrillation (percentage of time in atrial fibrillation on each Holter recording) at 3, 6, 12, or 18 months
    - at 2 years catheter ablation associated with
      - increased likelihood of being free from any atrial fibrillation (p
      - increased likelihood of being free from symptomatic atrial fibrillation (p
      - improved quality of life (physical component summary score) (p = 0.01)
      - decreased burden of atrial fibrillation (p = 0.007)
    - Reference – MANTRA-PAF trial (N Engl J Med 2012 Oct 25;367(17):1587), editorial can be found in N Engl J Med 2012 Oct 25;367(17):1648
  - 127 treatment-naive patients aged 18-75 years with symptomatic paroxysmal atrial fibrillation were randomized to radiofrequency catheter ablation vs. antiarrhythmic drugs and followed to 2 years
    - in radiofrequency catheter ablation group, antiarrhythmic drugs and electrical cardioversion allowed during first 90 days
    - in antiarrhythmic drug group, 69% received flecainide, 25% received propafenone, and 16.4% received ≥ 1 drug within 90 days, with dose titrated during first 90 days followed by maintenance dose
    - 42% of patients treated with antiarrhythmic drugs crossed over to radiofrequency catheter ablation after mean 362 days due to intolerance or inefficacy of medical treatment after 90 days of treatment
    - 86% in ablation group and 79% in antiarrhythmic drug group completed follow-up, but all patients included in intention-to-treat analyses
    - primary outcome was first documented atrial tachyarrhythmia > 30 seconds (including symptomatic or asymptomatic atrial fibrillation, atrial flutter, or atrial tachycardia)
    - comparing radiofrequency ablation vs. antiarrhythmic drug therapy
      - primary outcome in 54.5% vs. 72.1% (p = 0.02, NNT 6)
      - first recurrence of symptomatic atrial fibrillation, atrial flutter, atrial tachycardia in 47% vs. 59% (p = 0.03, NNT 9)
      - first recurrence of symptomatic atrial fibrillation in 41% vs. 57% (p = 0.02, NNT 7)
    - no significant differences in quality of life scores
    - no deaths or strokes occurred
    - Reference – RAAFT-2 trial (JAMA 2014 Feb 19;311(7):692), correction can be found in JAMA 2014 Jun 11;311(22):2337, editorial can be found in JAMA 2014 Feb 19;311(7):679
  - 198 patients (mean age 56 years) with paroxysmal atrial fibrillation without prior antiarrhythmic drug use were randomized to radiofrequency catheter ablation vs. antiarrhythmic drugs and followed for 4 years
    - antiarrhythmic drugs included flecainide, sotalol, and amiodarone alone or in combination
    - 87.9% patients treated with antiarrhythmic drugs crossed over to radiofrequency catheter ablation after 4-31 months (mean 10 months), 62 (71.3%) of whom maintained sinus rhythm following ablation
    - comparing radiofrequency catheter ablation vs. antiarrhythmic drugs in intention-to-treat analysis
      - freedom from atrial fibrillation and atrial tachycardia (after single radiofrequency ablation and off antiarrhythmic drugs, or after antiarrhythmic drugs alone) in 72.7% vs. 56.5% (p = 0.017, NNT 7)
      - freedom from atrial fibrillation and atrial tachycardia (after initial ablation or after repeat ablation and antiarrhythmic drugs) in 90.9% vs. 80.8% (NNT 10)
      - quality of life improved in both groups, no significant difference between groups
    - new left atrial tachycardia developed in 9 of 186 (4.8%) patients who had radiofrequency catheter ablation
    - procedural complications limited to short term and included
      - 3 femoral hematomas
      - 1 transient ischemic attack
      - 1 pericardial effusion
    - Reference – APAF trial (Circ Arrhythm Electrophysiol 2011 Dec;4(6):808)
  - all patients had > 2 atrial fibrillation episodes/month for 6 months
radiofrequency catheter ablation may reduce treatment failure compared to antiarrhythmic drug therapy in patients with paroxysmal atrial fibrillation not responding to ≥ 1 antiarrhythmic drug (level 2 [mid-level] evidence)
- based on randomized trial without blinding
- 167 patients (mean age 56 years) not responding to ≥ 1 antiarrhythmic drug and with ≥ 3 atrial fibrillation episodes within 6 months were randomized to catheter ablation vs. antiarrhythmic drug therapy and followed to 9 months
- treatment failure defined as any of
  - documented symptomatic paroxysmal atrial fibrillation during evaluation period
  - adverse event requiring discontinuation of antiarrhythmic drug therapy
  - for patients in ablation group with repeat ablation after 80 days, either of
    - absence of entrance block in all pulmonary veins at end of ablation
    - changes in specified drug regimen post blanking (even if free from symptomatic paroxysmal atrial fibrillation)
- comparing catheter ablation vs. antiarrhythmic drug therapy
  - treatment failure in 34% vs. 84% (p
  - major 30-day treatment-related adverse events in 4.9% vs. 8.8% (no p value reported)
- mean quality of life scores significantly improved with catheter ablation vs. antiarrhythmic drug therapy
- Reference – JAMA 2010 Jan 27;303(4):333, commentary can be found in JAMA 2010 May 12;303(18):1808
catheter reablation may reduce recurrent tachyarrhythmia compared to antiarrhythmic drugs following catheter ablation for persistent atrial fibrillation (level 3 [lacking direct] evidence)
- based on nonclinical outcome from randomized trial
- 201 patients (mean age 59 years and 69% male) with recurrent atrial tachycardia following catheter ablation for persistent atrial fibrillation randomized to catheter reablation vs. antiarrhythmic drugs for 2 years
- amiodarone was first-choice antiarrhythmic drug given at maintenance dose 200 mg/day orally
- comparing catheter reablation vs. antiarrhythmic drugs
  - freedom from recurrent tachyarrhythmia (including atrial fibrillation and atrial tachycardia) in 56.4% vs. 34% (p = 0.001, NNT 5)
  - periprocedural complications at 1 month in 7.9% vs. 0% (P = 0.012, NNH 12)
  - adverse events at ≥ 1 month in 10.9% vs. 24% (p = 0.014, NNT 8)
- catheter reablation associated with improved quality of life at 2 years (p
- Reference – Eur Heart J 2014 May 21;35(20):1327

considerations in patients with heart failure
- radiofrequency catheter ablation might improve exercise performance and quality of life compared to rate control therapy in adults with persistent atrial fibrillation and heart failure (level 2 [mid-level] evidence)
  - based on small randomized trial with allocation concealment not stated
  - 52 adults (mean age 63 years) with symptomatic heart failure, left ventricular ejection fraction (LVEF) ≤ 35%, and persistent atrial fibrillation randomized to radiofrequency catheter ablation vs. rate control therapy and followed for 12 months
  - in catheter ablation group, 88% had sinus rhythm without further arrhythmias after all procedures
  - in rate control group, 88% had rate control at 3 months
  - radiofrequency catheter ablation associated with
    - nonsignificantly increased 6-minute walk distance (p = 0.095)
    - improved Minnesota Living with Heart Failure Questionnaire score (p = 0.019)
    - increased peak oxygen consumption (p = 0.018)
    - decreased B-type natriuretic peptide levels (p = 0.045)
    - nonsignificantly increased left ventricle ejection fraction (p = 0.055)
  - Reference – J Am Coll Cardiol 2013 May 7;61(18):1894
- catheter ablation may reduce recurrence and mortality compared to amiodarone in adults with persistent atrial fibrillation, heart failure, and device implantation (level 2 [mid-level] evidence)
  - based on randomized trial without blinding
  - 203 patients (mean age 61 years) with persistent atrial fibrillation and New York Heart Association (NYHA) class II-III heart failure were randomized to catheter ablation vs. amiodarone 200 mg/day for 21 months (after 3-month blanking period following ablation)
    - in patients having catheter ablation, 22% had portal vein isolation and 78% had both portal vein and posterior wall isolation
    - amiodarone loading dose was 400 mg orally twice daily (weeks 0-2) and 400 mg once daily (weeks 2-4), then 200 mg/day for rest of trial
    - all patients had dual chamber implantable cardiovascular defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRTD) implantation and left ventricular ejection fraction (LVEF)
  - freedom from recurrence defined as no atrial fibrillation, atrial flutter, or atrial tachycardia lasting > 30 seconds without antiarrhythmic drugs
  - comparing catheter ablation vs. amiodarone at 24 months
    - freedom from recurrence in 70% vs. 34% (p
    - unplanned hospitalization in 31% vs. 57% (p
    - all-cause mortality 8% vs. 18% (p = 0.037, NNT 10)
  - catheter ablation associated with improved LVEF (p = 0.02), exercise capacity (p = 0.02), and quality of life (p = 0.04)
  - Reference – AATAC trial (Circulation 2016 Apr 26;133(17):1637 ), editorial can be found in Circulation 2016 Apr 26;133(17):1631
- catheter ablation of atrial fibrillation might improve left ventricular ejection fraction in patients with left ventricular systolic dysfunction (level 3 [lacking direct] evidence)
  - based on nonclinical outcome in systematic review
  - systematic review of 4 randomized trials and 22 observational studies evaluating catheter ablation of atrial fibrillation in 1,838 patients with left ventricular systolic dysfunction
  - most patients were symptomatic from heart failure
  - all patients underwent pulmonary vein isolation and had either additional linear lesions or focal ablation of complex fractionated atrial electrograms in left atrium at first or redo procedure
  - follow-up ranged from 18 to 40 months
  - catheter ablation of atrial fibrillation associated with
    - reduction in left ventricular ejection fraction (LVEF) dysfunction after first procedure (odds ratio [OR] 0.4, 95% CI 0.36-0.44) in analysis of 24 studies
    - reduction in LVEF dysfunction at end of follow-up (OR 0.6, 95% CI 0.54-0.67) in analysis of 23 studies
    - increased procedural complications (OR 4.17, 95% CI 3.59-4.83) in analysis of 18 studies
  - most procedural complications related to access site and to cerebral thromboembolic events
  - Reference – Circ Arrhythm Electrophysiol 2014 Dec;7(6):1011
- single catheter ablation associated with increased risk of recurrent atrial fibrillation or atrial tachycardia in patients with left ventricular systolic dysfunction (level 3 [lacking direct] evidence)
  - based on systematic review of mostly observational studies without clinical outcomes
  - systematic review of 8 studies (7 observational studies and 1 randomized trial) of catheter ablation for patients with atrial fibrillation with vs. without left ventricular systolic dysfunction (LVSD) in 1,851 patients
  - follow-up range 6-27 months
  - compared with absence of LVSD, presence of LVSD associated with increased risk of recurrent atrial fibrillation or atrial tachycardia following single catheter ablation (relative risk 1.45, 95% CI 1.2-1.75) in pooled analysis of 5 observational studies
  - Reference – Am J Cardiol 2010 Nov 1;106(9):1284
- catheter ablation for atrial fibrillation reported to improve quality of life and NYHA class in patients with heart failure (level 3 [lacking direct] evidence)
  - based on case series
  - 58 patients with NYHA class II heart failure (any cause) and documented ejection fraction
  - 58 patients with similar clinical and demographic characteristics but without heart failure also followed but no direct comparisons reported except for maintenance of sinus rhythm
  - patients followed for mean 12 months (range 3-34 months)
  - ablative therapy in patients with heart failure associated with
    - improvement in mean NYHA class (2.3 prior to 1.4 after ablation at 1 and 12 months, p
    - improvement in quality of life (SF 36) scores (p
    - improvements in exercise time and capacity (p
    - improvement in LVEF (mean 21%, p
  - no significant difference in number of patients in sinus rhythm at mean 12 months
  - Reference – N Engl J Med 2004 Dec 2;351(23):2373, editorial can be found inN Engl J Med 2004 Dec 2;351(23):2437, commentary can be found in N Engl J Med 2005 Mar 17;352(11):1148

Technique and target area for ablation

General considerations

catheter ablation of atrial fibrillation should target isolation of pulmonary veins (ESC Class IIa, Level A)⁽⁵⁾
Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECAS) recommendations regarding ablation technique (no grades given)⁽¹⁾
- strategies targeting pulmonary veins and/or pulmonary vein antrum are cornerstone for most atrial fibrillation (AF) ablation procedures
- electrical isolation is goal if pulmonary veins are targeted
- minimum requirement for achievement of electrical isolation is assessment and demonstration of entrance block into pulmonary vein
- consider monitoring for pulmonary vein reconduction for 20 minutes after initial pulmonary vein isolation
- for surgical pulmonary vein isolation, entrance and/or exit block should be demonstrated
- careful identification of pulmonary vein ostia mandatory to avoid ablation within pulmonary veins
- if focal trigger identified outside a pulmonary vein at time of an AF ablation procedure, consider ablation of that focal trigger
- if additional linear lesions applied, consider using mapping and pacing maneuvers to assess for line completeness
- ablation of cavotricuspid isthmus recommended in patients with history of typical atrial flutter or inducible cavotricuspid isthmus dependent atrial flutter
- if patients with long standing persistent AF are approached, consider more extensive ablation based on linear lesions or complex fractionated electrograms
- reduction of radiofrequency power recommended when creating lesions along posterior wall near esophagus
procedures used for catheter ablation of atrial fibrillation
- pulmonary vein isolation (PVI) (targeted at ablation of muscular sleeves)
  - ostial PVI
  - circular ostial PVI
  - segmental PVI
  - ablation of complex fractionated atrial electrograms (CFAE)
  - ablation of autonomic plexuses
- combined approaches
  - PVI plus ablation of vein of Marshall
  - PVI plus ablation of superior vena cava
  - inducibility guided additional ablation targeting the substrate
  - PVI plus adding linear lesions
    - mitral isthmus ablation
    - roofline ablation
    - ablation of anterior left atrial line
  - combinations of more than 2 techniques
  - double/single Lasso technique
- PV antrum isolation (PV antrum isolation guided by intracardiac echocardiography [ICE])
- wide anatomic circumferential ablation (encircling the PVs within the left atrium)
- stepwise ablation techniques
  - ablation of focal source in addition to PV foci
  - double atrium ablation
- Reference – Cochrane Database Syst Rev 2012 Apr 18;(4):CD007101

Pulmonary vein isolation (PVI)

encircling ablation and electrical isolation of pulmonary veins may reduce recurrence of atrial fibrillation in patients with persistent atrial fibrillation (level 2 [mid-level] evidence)
- based on systematic review without assessment of allocation concealment
- systematic review of 32 randomized trials and 14 observational studies evaluating catheter ablation in 6,085 patients with atrial fibrillation
- 23 studies enrolled only patients with persistent atrial fibrillation, remaining studies enrolled mixed populations
- all analyses limited to patients with persistent atrial fibrillation
- significant reduction in recurrent atrial fibrillation with
  - pulmonary vein encircling ablation (alone or with complex fractionated atrial electrograms [CFAEs]) compared to control (left atrial linear lesions or CFAEs alone) in analysis of 3 studies with 182 patients
    - odds ratio (OR) 0.26 (95% CI 0.09-0.74)
    - NNT 2-16 with recurrent atrial fibrillation in 74% of control group
  - electrical isolation of pulmonary veins compared to no electrical isolation in analysis of 4 studies with 268 patients, results limited by significant heterogeneity
    - OR 0.33 (95% CI 0.13-0.86)
    - NNT 3-29 with recurrent atrial fibrillation in 65% of no electrical isolation group
- Reference – Circ Arrhythm Electrophysiol 2014 Oct;7(5):841

PVI associated with improved quality of life compared to atrioventricular node ablation with biventricular pacing in patients with drug-refractory atrial fibrillation and heart failure (level 2 [mid-level] evidence)
- based on randomized trial without blinding
- 81 patients with symptomatic, drug-resistant atrial fibrillation, ejection fraction ≤ 40%, and New York Heart Association (NYHA) class II-III heart failure randomized to PVI vs. atrioventricular node ablation with biventricular pacing and followed for 6 months
- comparing PVI vs. atrioventricular node ablation at 6 months
  - pulmonary vein isolation associated with improved quality of life (p
  - mean ejection fraction 35% vs. 28% (p
  - mean 6-minute walk distance 340 meters vs. 297 meters (p
- among patients treated with PVI, 88% free from atrial fibrillation (with or without medication) and 71% not receiving drugs
- Reference – N Engl J Med 2008 Oct 23;359(17):1778

wide area circumferential ablation might reduce recurrent atrial fibrillation compared to segmental pulmonary vein isolation in patients with persistent atrial fibrillation (level 2 [mid-level] evidence)
- based on systematic review without assessment of allocation concealment
- systematic review of 32 randomized trials and 14 observational studies evaluating catheter ablation in 6,085 patients with atrial fibrillation
- 23 studies enrolled only patients with persistent atrial fibrillation, remaining studies enrolled mixed populations
- all analyses limited to patients with persistent atrial fibrillation
- wide area circumferential ablation associated with nonsignificant reduction in recurrent atrial fibrillation compared to segmental pulmonary vein isolation (odds ratio 0.41, 95% CI 0.15-1.1) in analysis of 3 studies with 107 patients
- Reference – Circ Arrhythm Electrophysiol 2014 Oct;7(5):841
- catheter ablation with isolation of large areas around pulmonary veins may reduce symptoms more than isolation of small areas in patients with highly symptomatic, drug-refractory paroxysmal, or persistent atrial fibrillation (level 2 [mid-level] evidence)
  - based on randomized trial without blinding
  - 110 patients with highly symptomatic, drug-refractory paroxysmal, or persistent episodes of atrial fibrillation randomized to radiofrequency ablation and isolation of large area around both ipsilateral pulmonary veins vs. isolation of each individual pulmonary vein
  - mean follow-up 15 months
  - absence of symptomatic atrial fibrillation and of tachyarrhythmias (monitored or during exercise testing) in 67% with large area isolation vs. 49% with small area isolation (p ≤ 0.05, NNT 6)
  - Reference – Circulation 2007 Jun 19;115(24):3057 full-text, commentary can be found in Circulation 2007 Dec 18;116(25):e575 full-text

addition of targeted ablation of dormant pulmonary vein conduction identified by adenosine testing after radiofrequency ablation for paroxysmal AF reduces symptomatic atrial tachyarrhythmia (level 1 [likely reliable] evidence)
- based on randomized trial
- 546 adults (mean age 60 years, 69% men) with ≥ 3 symptomatic AF episodes in previous 6 months and failure of ≥ 1 antiarrhythmic drug, but no previous ablation procedures had radiofrequency catheter ablation for pulmonary vein isolation
  - after initial ablation procedure, all patients had 20-minute observation period to assess spontaneous conduction recovery with additional ablation if necessary until sustained isolation of pulmonary veins was confirmed
  - after confirmed isolation, all patients had sequential provocative testing with adenosine IV ≥ 12 mg per vein to assess dormant conduction (reappearance of conduction for ≥ 1 beat)
  - 284 adults with dormant pulmonary vein conduction randomized to targeted ablation vs. no additional ablation and followed for 1 year
  - 117 patients without dormant conduction were randomly allocated to registry group with identical follow-up to patients with dormant conduction
- all patients had oral anticoagulant for ≥ 2 months and could have antiarrhythmic drugs (not amiodarone) for up to 3 months after ablation
- primary outcome was freedom from symptomatic atrial tachyarrhythmia without additional ablation procedure from 3 months to 1 year after ablation (excluding period of possible use of antiarrhythmics)
- patients and outcome assessors were blinded to treatment
- dormant conduction eliminated in 97% of patients randomized to targeted ablation
- rates of freedom from symptomatic atrial tachyarrhythmia without additional ablation
  - 69.4% with targeted ablation (p
  - 42.3% with no additional ablation
  - 55.7% in registry group (patients with no dormant conduction on adenosine testing)
- consistent findings for freedom from any atrial tachyarrhythmia
- Reference – ADVICE trial (Lancet 2015 Aug 15;386(9994):672), editorial can be found in Lancet 2015 Aug 15;386(9994):633

addition of adenosine testing to guide further ablation for all patients having PVI for AF may not reduce recurrent atrial tachyarrhythmias compared to conventional PVI (level 2 [mid-level] evidence)
- based on randomized trial with baseline differences
- 2,113 patients (mean age 63 years, 75% men) AF were randomized to adenosine triphosphate (ATP)-guided PVI vs. conventional PVI without adenosine testing and followed for 12 months
  - paroxysmal AF in 67.2%
  - persistent AF in 22.7%
  - long-lasting AF in 10.1%
- in ATP-guided PVI group, ATP 0.4 mg/kg body weight IV given at median 57 minutes after PVI to unmask dormant conduction
  - dormant conduction unmasked in 489 pulmonary veins in 307 patients (27.6%)
  - additional radiofrequency energy applications (median 5 times for applications for median 2.5 minutes) eliminated dormant conduction in 302 patients (98.4%)
- significant baseline differences between groups included gender, age, CHADS₂score, prior stroke or transient ischemic attack, and use of antiplatelet drugs
- comparing ATP-guided PVI vs. conventional PVI at baseline
  - mean age 59 vs. 69 (p
  - hypertension in 47.6% vs. 58.9% (p
  - prior stroke or transient ischemic attack 5.9% vs 10.8% (p
  - antiplatelet drug use in 8% vs. 13.2% (p
- primary outcome was recurrent atrial tachyarrhythmias lasting for > 30 seconds or those requiring repeat ablation, hospital admission, or use of Vaughan Williams class I or III antiarrhythmic drugs at 12 months (after 90-day blanking period following ablation procedure)
- freedom from primary outcome in 68.7% with ATP-guided PVI vs. PVI 67.1% with conventional PVI (not significant)
- consistent results in subgroups of patients with paroxysmal AF and patients with persistent or long-lasting AF
- no significant differences in total procedure time, fluoroscopy time or radiation dose, or peri-procedural complications
- Reference – UNDER-ATP trial (Eur Heart J 2015 Dec 7;36(46):3276)
- DynaMed commentary — In the ADVICE trial above, only patients with dormant pulmonary vein conduction on adenosine testing were randomized to additional targeted ablation vs. no additional ablation. In the UNDER-ATP trial, patients were randomized to adenosine testing plus additional ablation if dormant conduction found vs. no adenosine testing (conventional PVI). The prevalence of dormant conduction was much lower (27.6% in the testing group) in UNDER-ATP than in ADVICE (52%).

addition of step wise ablation to PVI reduces recurrence of atrial fibrillation at 1 year in patients with paroxysmal atrial fibrillation and structural atrial disease (level 1 [likely reliable] evidence)
- based on randomized trial
- 150 patients (mean age 63 years, 61% male) with medication-refractory paroxysmal atrial fibrillation and structural atrial disease were randomized to 1 of 2 PVI procedures and were followed up to 1 year
  - PVI during rapid atrial pacing-induced atrial fibrillation with additional stepwise ablation of complex fractionated atrial electrograms if atrial fibrillation was ongoing or inducible to restore normal sinus rhythm
  - PVI of all 4 pulmonary veins during normal sinus rhythm (induced with electrical cardioversion if necessary) with ablation confirmed with entrance block
- antiarrhythmic therapy was discontinued 3 months after procedure in all patients
- mean procedural duration 148 minutes for PVI with stepwise ablation vs. 105 minutes for PVI alone (p
- comparing PVI with stepwise ablation vs. PVI alone
  - recurrence of atrial fibrillation or atrial tachycardia ≥ 30 seconds
    - at 6 months in 24% vs. 45.3% (p = 0.006, NNT 5)
    - at 1 year in 26.7% vs. 46.7% (p
  - repeat procedure performed in 25.3% vs. 44% (no p value reported)
  - recurrence of atrial fibrillation or atrial tachycardia ≥ 30 seconds in 52 patients with repeat procedure
    - at 6 months in 21% vs. 51.5% (p = 0.031, NNT 4)
    - at 1 year in 31.6% vs. 63.6% (p = 0.026, NNT 4)
- no significant difference in rates of ablation complications after first or second procedures, with overall rate of complication 10% for first procedure and 5.8% for repeat procedure
- most common complications included femoral hematoma and pericarditis
- cardiac tamponade requiring pericardiocentesis reported in 2 patients receiving stepwise ablation
- Reference – Heart Rhythm 2015 Sep;12(9):1907, editorial can be found Heart Rhythm 2015 Sep;12(9):1916

circumferential left atrial ablation appears more effective than segmental pulmonary vein isolation for preventing recurrent symptomatic paroxysmal atrial fibrillation (level 2 [mid-level] evidence)
- based on randomized trial without description of randomization
- 80 patients with paroxysmal atrial fibrillation randomized to segmental pulmonary vein ablation vs. circumferential left atrial ablation and followed for 6 months
- comparing pulmonary vein isolation vs. left atrial circumferential ablation, freedom from atrial fibrillation at 6 months (not counting first 4 weeks) in 67% vs. 88% (p = 0.02, NNT 5 for left atrial ablation)
- Reference – Circulation 2003 Nov 11;108(19):2355 full-text
segmental pulmonary vein isolation might reduce left atrial flutter compared with circumferential pulmonary vein ablation (level 3 [lacking direct] evidence) without reducing medication use (level 2 [mid-level] evidence) in patients with paroxysmal atrial fibrillation
- based on randomized trial with allocation concealment not stated
- 66 patients with paroxysmal atrial fibrillation randomized to segmental pulmonary vein isolation vs. circumferential pulmonary vein ablation with additional linear ablation
- mean follow-up 16.4 months
- comparing segmental pulmonary vein isolation vs. circumferential pulmonary vein ablation
  - patients free of atrial arrhythmias and off antiarrhythmic therapy 58% vs. 52% (not significant)
  - recurrent paroxysmal atrial fibrillation in 42% vs. 24% (not significant)
  - atypical left atrial flutter in 0% vs. 24% (p = 0.002, NNT 5)
- Reference – Circ Arrhythm Electrophysiol 2010 Jun 1;3(3):243 full-text
addition of renal artery denervation to pulmonary vein isolation may decrease recurrence of atrial fibrillation at 1 year in patients with symptomatic paroxysmal or persistent atrial fibrillation (level 3 [lacking direct] evidence)
- based on nonclinical outcome from small randomized trial
- 27 patients (mean age 57 years) with symptomatic paroxysmal or persistent atrial fibrillation refractory to ≥ 2 antiarrhythmic drugs randomized to pulmonary vein isolation (PVI) plus renal artery denervation vs. PVI alone
- all patients had drug-resistant hypertension defined as systolic blood pressure > 160 mm Hg despite triple drug therapy at baseline
- freedom from atrial fibrillation at 1 year in 69% with PVI plus renal artery denervation vs. 29% with PVI alone (p = 0.033, NNT 3)
- PVI plus renal artery denervation associated with decreased mean systolic and diastolic blood pressure compared to baseline (p
- Reference – J Am Coll Cardiol 2012 Sep 25;60(13):1163
addition of intervenous ridge ablation to circumferential antral pulmonary vein isolation may not reduce atrial fibrillation recurrence in patients with symptomatic paroxysmal atrial fibrillation (level 3 [lacking direct] evidence)
- based on nonclinical outcome from randomized trial with high crossover rate
- 234 patients (mean age 59 years) with highly symptomatic paroxysmal atrial fibrillation refractory to medical management were randomized to circumferential antral pulmonary vein isolation with intervenous ridge (IVR) ablation (maximal ablation) vs. circumferential antral pulmonary vein isolation alone (minimal ablation)
- mean follow-up 17 months
- all patients had successful pulmonary vein isolation
- 44% in minimal ablation group required IVR ablation to achieve pulmonary vein isolation
- comparing maximal ablation vs. minimal ablation in intention-to-treat analysis
  - freedom from atrial fibrillation after single procedure in 62% vs. 70% (not significant)
  - repeat procedures in 24% vs. 17% (not significant)
  - complications in 1.7% vs. 2.6% (no p value reported)
- no significant differences between groups in echocardiographic outcomes or quality of life
- in subgroup analyses comparing successful minimal ablation vs. minimal ablation requiring IVR ablation
  - freedom from atrial fibrillation in 80% vs. 57% (p
  - repeat procedures in 11% vs. 26% (p = 0.03)
- Reference – Eur Heart J 2015 Jul 21;36(28):1812

Atrial ablation

biatrial ablation has limited evidence to evaluate efficacy compared to left atrial ablation in patients with persistent atrial fibrillation
- based on systematic review
- systematic review of 32 randomized trials and 14 observational studies evaluating catheter ablation in 6,085 patients with atrial fibrillation
- 23 studies enrolled only patients with persistent atrial fibrillation, remaining studies enrolled mixed populations
- all analyses limited to patients with persistent atrial fibrillation
- 3 trials compared biatrial ablation to left atrial ablation
  - no significant difference in recurrent atrial fibrillation with addition of
    - right atrial complex fractionated atrial electrograms to left atrial ablation plus direct current cardioversion in 1 trial with 66 patients
    - superior vena cava isolation to pulmonary vein antrum isolation in 1 trial with 160 patients
  - addition of superior vena cava isolation plus intercaval septal and posterior lines to pulmonary vein isolation plus mitral isthmus line plus cavotricuspid isthmus significantly reduced recurrent atrial fibrillation in 1 trial (below)
- Reference – Circ Arrhythm Electrophysiol 2014 Oct;7(5):841
- biatrial ablation appears more effective than left atrial ablation for persistent atrial fibrillation (level 2 [mid-level] evidence)
  - based on randomized trial without blinding
  - 80 symptomatic patients with persistent or permanent atrial fibrillation despite 3 cardioversion attempts or 3 antiarrhythmic drug control attempts randomized to biatrial vs. left atrial ablation and followed for mean 14 months
    - left atrial ablation included ablation of circumferential lines at least 1 cm from pulmonary vein ostia, mitral isthmus, and cavotricuspid isthmus
    - biatrial ablation included intercaval posterior line, intercaval septal line, and electrical disconnection of superior vena cava
  - all patients given amiodarone and anticoagulation for ≥ 6 months after procedure
  - atrial fibrillation defined as confirmed episode > 30 seconds on Holter monitoring which was done every 3 months or if symptoms
  - comparing biatrial ablation vs. left atrial ablation, atrial fibrillation recurrence in 15% vs. 39% (p = 0.022, NNT 5 for biatrial ablation)
  - Reference – J Am Coll Cardiol 2006 Jun 20;47(12):2504 full-text

Ablation of complex fractionated electrograms

addition of complex fractionated atrial electrograms to single ablation procedure may not reduce recurrence of atrial fibrillation in patients with persistent atrial fibrillation (level 2 [mid-level] evidence)
- based on systematic review limited by clinical heterogeneity
- systematic review of 32 randomized trials and 14 observational studies evaluating catheter ablation in 6,085 patients with atrial fibrillation
  - 23 studies enrolled only patients with persistent atrial fibrillation, remaining studies enrolled mixed populations
  - all analyses limited to patients with persistent atrial fibrillation
- 7 trials evaluated addition of complex fractionated atrial electrograms (CFAE) ablation to single ablation procedure
- no significant difference in recurrent atrial fibrillation in overall analysis of 7 studies with 532 patients, results limited by heterogeneity in primary ablation procedure
- in individual studies, no significant difference in recurrent atrial fibrillation with addition of CFAE ablation to
  - left atrial ablation plus direct current cardioversion in 1 trial with 66 patients
  - antral ablation plus direct current cardioversion in 1 trial with 100 patients
- mixed results for addition of CFAE ablation to pulmonary vein antral isolation (PVAI)
  - addition of CFAE to PVAI significantly decreased recurrent atrial fibrillation in 1 trial with 97 patients
  - recurrent atrial fibrillation in 17.5% with CFAE plus PVAI vs. 27.5% with PVAI alone (not significant) in 1 study with 80 patients
- recurrent atrial fibrillation in
  - 33.3% with CFAE ablation plus wide area circumferential ablation plus lines vs. 63.3% with wide area circumferential ablation plus lines alone (p
  - 70.6% with CFAE ablation plus pulmonary vein ablation plus ablation of nonpulmonary vein triggers vs. 50.9% with pulmonary vein ablation plus ablation of nonpulmonary vein triggers alone (p
  - 16.7% with CFAE plus pulmonary vein isolation vs. 54.5% with pulmonary vein isolation alone (not significant) in 1 trial with 23 patients
- Reference – Circ Arrhythm Electrophysiol 2014 Oct;7(5):841

pulmonary vein antral isolation in sinus rhythm may increase arrhythmia-free and medication-free survival compared to ablation of complex fractionated atrial electrograms in atrial fibrillation (level 2 [mid-level] evidence)
- based on randomized trial without blinding
- 90 patients (mean age 63 years, 74% male) with persistent atrial fibrillation for ≥ 3 months resistant or intolerant to antiarrhythmic drugs having pulmonary vein antral isolation (PVAI) plus posterior wall and septum ablation were randomized to 1 of 2 procedures
  - preprocedural direct current cardioversion to perform ablation in sinus rhythm
  - ablation performed in atrial fibrillation with additional ablation of complex fractionated atrial electrograms
- both groups had same PVAI ablation strategy and left atrial ablations lines
- median follow-up was 867 days
- 24% in normal sinus rhythm group and 43% of atrial fibrillation group had challenge with isoproterenol or adenosine
- recurrence defined as atrial fibrillation, atrial flutter, or focal atrial tachycardia lasting > 30 seconds after 3-month blanking period
- comparing ablation in sinus rhythm vs. ablation in atrial fibrillation
  - median arrhythmia-free survival without antiarrhythmic medication 600 days vs. 150 days (estimated from figure, p = 0.04)
  - arrhythmia-free without antiarrhythmic medication for 1 year in 35% vs. 30% (no p value reported)
  - use of antiarrhythmic medication at last follow-up in 39% vs. 41% (no p value reported)
  - repeat ablation procedures in 26% vs. 31.8% (no p value reported)
  - mean procedural duration was 231 minutes vs. 273 minutes (p = 0.008)
  - median fluoroscopy duration was 53.8 minutes vs. 65.6 minutes (p = 0.018)
- pulmonary vein stenosis requiring stenting occurred in 1 patient in sinus rhythm group
- Reference – Circ Arrhythm Electrophysiol 2016 Feb;9(2):e003596

cardiac autonomic denervation plus pulmonary vein isolation may increase freedom from recurrence of atrial fibrillation compared to pulmonary vein isolation alone (level 3 [lacking direct] evidence)
- based on systematic review without clinical outcomes
- systematic review of 15 studies (9 randomized trials, 6 nonrandomized trials) comparing cardiac autonomic denervation plus pulmonary vein isolation vs. pulmonary vein isolation alone in 1,147 patients with atrial fibrillation
- cardiac autonomic denervation included ablation of complex fractionated atrial electrograms and ablation of ganglionated plexi
- cardiac autonomic denervation plus pulmonary vein isolation associated with increased freedom from atrial fibrillation
  - overall (odds ratio [OR] 1.85, 95% CI 1.33-2.59) in analysis of 10 studies with 887 patients
  - in patients with paroxysmal atrial fibrillation (OR 1.69, 95% CI 1.09-2.62) in analysis of 6 studies with 457 patients
  - in patients with nonparoxysmal atrial fibrillation (OR 2.11, 95% CI 1.14-3.9) in analysis of 5 studies with 360 patients
- Reference – J Cardiovasc Electrophysiol 2012 Jun;23(6):592
trials of addition of ablation of complex fractionated electrograms to pulmonary vein isolation have mixed results
- addition of either ablation of complex fractionated electrograms or linear ablation to pulmonary-vein isolation does not appear to reduce rates of recurrent atrial fibrillation in patients with persistent atrial fibrillation having catheter ablation (level 2 [mid-level] evidence)
  - based on randomized trial without intention-to-treat analysis
  - 589 adults with symptomatic persistent atrial fibrillation refractory to ≥ 1 antiarrhythmic agent having catheter ablation were randomized to 1 of 3 interventions and followed for 18 months
    - pulmonary-vein isolation plus ablation of complex fractionated electrograms (isolation plus electrograms)
    - pulmonary-vein isolation plus linear ablation across left atrial roof and mitral valve isthmus (isolation plus lines)
    - pulmonary-vein isolation alone
  - 90% completed 18-month follow-up
  - primary outcome was documented recurrence of atrial fibrillation lasting ≥ 30 seconds after 1 procedure
  - rates of freedom from primary outcome (p = 0.15 among groups, no pairwise p values reported)
    - 49% with isolation plus electrograms
    - 46% with isolation plus lines
    - 59% with isolation alone
  - rates of repeat ablation (p = 0.1 among groups, no pairwise p values reported)
    - 26% with isolation plus electrograms
    - 33% with isolation plus lines
    - 21% with isolation alone
  - isolation alone associated with significantly reduced procedure time and fluoroscopy exposure vs. other procedures (p
  - no significant differences among groups in freedom from documented atrial fibrillation after 2 procedures, freedom from documented atrial arrhythmia, documented atrial flutter or tachycardia, or adverse events
  - Reference – STAR AF II trial (N Engl J Med 2015 May 7;372(19):1812)
- ablation of complex fractionated atrial electrograms does not appear to improve clinical outcomes compared to cardioversion for persistent atrial fibrillation after antral pulmonary vein isolation (level 2 [mid-level] evidence)
  - based on randomized trial with inadequate statistical power
  - 119 consecutive patients (mean age 60 years) with persistent atrial fibrillation had antral pulmonary vein isolation (APVI), 19 had termination of atrial fibrillation with APVI
  - 100 patients with persistent atrial fibrillation after APVI randomized to up to 2 hours of ablation of complex fractionated atrial electrograms (during same procedure) vs. cardioversion
  - mean follow-up 10 months
  - comparing complex fractionated atrial electrograms ablation vs. cardioversion, no significant difference in sinus rhythm without antiarrhythmic drugs
  - Reference – J Am Coll Cardiol 2009 Mar 3;53(9):782, editorial can be found in J Am Coll Cardiol 2009 Mar 3;53(9):790
- combined ablation of pulmonary vein isolation and complex fractionated electrograms terminated atrial fibrillation more effectively than either treatment alone in patients with high-burden paroxysmal/persistent atrial fibrillation (level 3 [lacking direct] evidence)
  - based on randomized trial without clinical outcomes
  - 101 patients (mean age 57 years) with drug-refractory, high-burden paroxysmal or persistent atrial fibrillation were randomized to pulmonary vein isolation (PVI) vs. complex fractionated electrograms (CFE) vs. combination PVI and CFE and followed for 12 months
    - high burden defined as > 4 episodes in 6 months of AF lasting > 6 hours
    - persistent defined as episodes for > 7 days but
    - asymptomatic atrial fibrillation not considered clinical outcome
  - patients continued on warfarin (target INR 2-3) for ≥ 3 months, and antiarrhythmic medications for 2 months post-ablation
  - single repeat ablation (same strategy as initial ablation) allowed at 3-6 months if needed
  - 1 patient did not receive PVI and not included in analysis
  - repeat ablation required in
    - 15% with combination PVI and CFE
    - 31% with PVI (p = 0.07 vs. combination)
    - 47% with CFE (p = 0.008 vs. combination, not significant vs. PVI)
  - freedom from atrial fibrillation recurrence after single ablation (on and off antiarrhythmic medications)
    - 74% with combination PVI and CFE
    - 48% with PVI (p = 0.03 vs. combination)
    - 29% with CFE (p
  - freedom from atrial fibrillation recurrence after repeat ablation (on and off antiarrhythmic medications)
    - 88% with combination PVI and CFE
    - 68% with PVI (p = 0.04 vs. combination)
    - 38% with CFE (p
  - Reference – STAR-AF trial (Eur Heart J 2010 Jun;31(11):1344 full-text)
- addition of ibutilide to catheter ablation of complex fractionated atrial electrograms after pulmonary vein isolation may not increase freedom from atrial arrhythmia without need for medication in patients with persistent atrial fibrillation (level 2 [mid-level] evidence)
  - based on randomized trial without intention-to-treat analysis
  - 200 patients with persistent atrial fibrillation having first-ever catheter ablation were randomized to ibutilide-augmented ablation of complex fractionated atrial electrograms vs. placebo-augmented ablation after pulmonary vein isolation and were followed for 1 year
  - 92% completed follow-up and 95% included in analyses
  - comparing ablation with ibutilide vs. ablation with placebo
    - freedom from atrial arrhythmia without need for anti-arrhythmic medication at 1 year in 56% vs. 49% (not significant)
    - atrial fibrillation termination during ablation procedure in 75% vs. 57% (p = 0.007)
    - mean reduction in left atrial surface area exhibiting complex fractionated atrial electrograms 8% vs. 1% (p
  - no significant differences in periprocedural complications including congestive heart failure requiring diuretics or hospitalization and pericarditis/pericardial effusion
  - Reference – MAGIC-AF trial (Eur Heart J 2016 May 21;37(20):1614)

Ablation of additional areas

focal impulse and rotor modulation guided ablation associated with higher rates of long-term freedom from atrial fibrillation than conventional trigger ablation alone (level 3 [lacking direct] evidence)
- based on nonclinical outcomes in follow-up study from randomized trial
- 92 patients with AF who had novel computational mapping and were randomized to focal impulse and rotor modulation guided ablation vs. conventional ablation alone included
- median 890 days follow-up
- freedom from atrial fibrillation 77.8% with focal impulse and rotor modulation guided ablation vs. 38.5% with conventional ablation (p = 0.001)
- Reference – J Am Coll Cardiol 2014 May 6;63(17):1761
addition of left atrial ganglionated plexi ablation before pulmonary vein isolation may increase freedom from arrhythmia in patients with paroxysmal atrial fibrillation (AF) (level 3 [lacking direct] evidence)
- based on randomized trial without clinical outcomes
- 67 patients with paroxysmal AF randomized to anatomic left atrial ganglionated plexi (GP) modification followed by pulmonary vein isolation (PVI) catheter ablation vs. PVI catheter ablation only and followed for 12 months
- comparing GP modification vs. PV ablation alone
  - arrhythmia-free at 12 months in 85.3% vs. 60.6% (p = 0.019, NNT 4)
  - arrhythmia recurrence at 5 months in 26.5% vs. 54.5% (no p value reported)
  - repeat ablation at 5 months in 17.6% vs. 21.2% (no p value reported)
- Reference – Heart Rhythm 2011 May;8(5):672
addition of superior vena cava isolation to pulmonary vein antrum isolation may improve rate of conversion to sinus rhythm in patients with paroxysmal atrial fibrillation (level 3 [lacking direct] evidence)
- based on subgroup analysis of randomized trial without clinical outcomes
- 320 patients having first-time ablation for atrial fibrillation (46% paroxysmal, 23% persistent, 31% permanent) randomized to superior vena cava isolation (SVCI) plus pulmonary vein antrum isolation (PVAI) vs. PVAI alone
- SVCI not performed (and patients excluded from analysis) in 16% of SVCI plus PVAI group due to technological difficulties (either phrenic nerve capture or lack of superior vena cava potentials)
- comparing SVCI plus PVAI vs. PVAI alone
  - sinus rhythm maintained at 12 months in 81% vs. 74% (not significant)
  - sinus rhythm maintained at 12 months (in subgroup of patients with paroxysmal atrial fibrillation only) in 90% vs. 77% (p = 0.04)
- Reference – J Cardiovasc Electrophysiol 2010 Jan;21(1):1
addition of prophylactic cavotricuspid isthmus block to circumferential pulmonary vein ablation not associated with increased rates of freedom from atrial fibrillation or flutter compared to ablation alone (level 3 [lacking direct] evidence)
- based on randomized trial without clinical outcomes and with inadequate statistical power
- 149 patients with atrial fibrillation and no history of atrial flutter randomized to circumferential pulmonary vein ablation plus prophylactic cavotricuspid isthmus block vs. circumferential pulmonary vein ablation alone
- patients followed for 12 months with 7-day Holter monitoring at 3, 6, and 12 months
- no significant differences comparing ablation plus cavotricuspid isthmus block vs. ablation alone in
  - cumulative atrial flutter-free rate (88% vs. 84%)
  - cumulative atrial fibrillation-free rate (34% vs. 32%)
- Reference – Heart 2009 Jun;95(12):994

addition of linear ablation to circumferential pulmonary vein ablation may not prevent clinical recurrence of atrial fibrillation regardless of bidirectional block achievement (level 2 [mid-level] evidence)
- based on randomized trial with allocation concealment not stated
- 156 patients (76% male, mean age 56 years) with symptomatic drug-refractory paroxysmal AF having circumferential pulmonary vein ablation randomized to 1 of 3 additional treatments
  - linear ablation with bidirectional block via roof line on left atrium with pacing from appendage to posterior wall
  - linear ablation with posterior inferior line connecting lower margins of right and left circumferential pulmonary vein isolation lines
  - no additional treatment (control)
- mean follow-up 15.6 months
- no significant differences among groups in clinical recurrence
- both linear ablation groups associated with increased total procedural time and ablation compared to control (p ≤ 0.035 for each)
- Reference – Heart 2012 Mar;98(6):480 full-text

Technological support for catheter navigation or mapping

strategies for mapping and ablation of linear ablation lines⁽¹⁾
- diagnostic mapping (12-lead electrocardiogram, 3-dimensional electro-anatomic mapping)
- ablation of left atrial flutter
addition of circular mapping catheter to verify isolation of pulmonary vein antrum associated with increased rate of medication-free arrhythmia resolution (level 2 [mid-level] evidence)
- based on randomized trial with allocation concealment not stated
- 146 consecutive patients with atrial fibrillation having circumferential pulmonary vein ablation were randomized to radiofrequency catheter vs. addition of circular mapping catheter to assess electrical activity of the pulmonary vein antrum and followed at 1, 3, and 6 months after ablation and every 6 months thereafter if symptoms persisted
- mean follow-up 9 months
- comparing radio frequency catheter alone vs. addition of circular mapping catheter
  - arrhythmia-free without antiarrhythmic medication in 42.5% vs. 64.4% (p = 0.008, NNT 5)
  - severe procedure-related complications in 1.4% vs. 4.1% (not significant)
- Reference – Heart Rhythm 2010 May;7(5):612
manually controlled steerable sheath catheter navigation for ablation may increase rhythm control at 3-6 months in patients with paroxysmal or persistent drug-refractory atrial fibrillation having first ablation (level 3 [lacking direct] evidence)
- based on randomized trial without clinical outcomes
- 130 patients with paroxysmal or persistent drug-refractory atrial fibrillation having first ablation procedure were randomized to catheter ablation using manually controlled steerable transseptal sheath catheter navigation vs. conventional nonsteerable sheath
- comparing steerable vs. nonsteerable sheath catheter navigation
  - mean periprocedural fluoroscopy time 33 minutes vs. 45 minutes (p
  - no atrial fibrillation or atrial macroreentrant tachycardia at 3 months in 78% vs. 55% (p = 0.005, NNT 5)
  - no atrial fibrillation or atrial macroreentrant tachycardia at 6 months in 76% vs. 53% (p = 0.008, NNT 5)
  - no significant differences in
    - rate of pulmonary vein isolation
    - procedure duration
    - radiofrequency application time
    - complication rates
- Reference – Circ Arrhythm Electrophysiol 2011 Apr 1;4(2):157 full-text
robotic navigation for pulmonary vein isolation associated with similar effectiveness but less fluoroscopy time compared with conventional ablation (level 3 [lacking direct] evidence)
- based on randomized trial without clinical outcomes
- 60 patients with drug-refractory, highly symptomatic paroxysmal atrial fibrillation having pulmonary vein isolation were randomized to nonmagnetic robotic navigation system vs. conventional ablation
- patients followed-up for 6 months
- comparing robotic navigation vs. conventional ablation
  - fluoroscopy time 9 minutes vs. 22 minutes (p
  - atrial fibrillation-free rate at 6 months 73% vs. 77% (not significant)
- Reference – J Cardiovasc Electrophysiol 2010 Jan;21(1):6

Cryoballoon ablation

cryoballoon ablation may be more successful than drug treatment for atrial fibrillation in patients for whom at least one antiarrhythmic drug has failed (level 2 [mid-level] evidence)
- based on randomized trial without blinding
- 245 patients with symptomatic paroxysmal or early persistent atrial fibrillation (AF) and previously failed therapy with ≥ 1 antiarrhythmic drug were randomized to cryoballoon ablation (with second procedure allowed if needed) vs. antiarrhythmic therapy with drug not previously tried (with option of cryoablation if persistent AF)
- during 90 day blanking period
  - arrhythmias were not considered recurrences in either group
  - patients in cryoballoon ablation could receive antiarrhythmic study drugs (flecainide, propafenone, or sotalol)
- patients assessed at 1, 3, 6, 9, and 12 months, and patients in drug treatment group allowed to cross over after blanking period if persistent AF
- treatment success defined as
  - absence of detectable AF after blanking period
  - no use of nonstudy antiarrhythmic drug
  - no nonprotocol intervention
- 79.3% of drug treatment group crossed over to ablation prior to 12-month assessment due to recurrent AF on drug therapy
- treatment success at 12 months in 69.9% with cryoablation vs. 7.3% with drug treatment (p
- freedom from any AF at 12 months after single cryoablation procedure occurred in 63.7% of cryoablation patients and 61.6% of drug treatment patients who crossed over after drug failure (not significant)
- serious adverse events occurred in 3.1% of patients undergoing cryoablation (including, myocardial infarction, atrial flutter, cardiac tamponade, pulmonary vein stenosis)
- Reference – J Am Coll Cardiol 2013 Apr 23;61(16):1713

cryoballoon ablation is as effective as radiofrequency ablation for treatment of symptomatic paroxysmal atrial fibrillation refractory to antiarrhythmic drugs or beta blockers (level 1 [likely reliable] evidence)
- based on randomized trial
- 762 patients (mean age 60 years) having pulmonary-vein isolation for symptomatic paroxysmal atrial fibrillation refractory to class I or class III antiarrhythmic drugs or beta blockers were randomized to cryoballoon ablation vs. radiofrequency ablation
- patients in cryoballoon ablation group had higher prevalence of chronic kidney disease and type 2 diabetes at baseline (p
- mean follow-up 1.5 years
- 98.4% underwent catheter ablation (91% without major protocol violations) and were included in modified intention-to-treat analysis
- primary efficacy outcome was clinical failure defined as recurrence of atrial fibrillation, incidence of atrial flutter or atrial tachycardia, use of antiarrhythmic drugs, or repeat ablation at 90-360 days and was evaluated by blinded outcome assessors
- primary safety outcome was composite of all-cause death, stroke or transient ischemic attack, or serious treatment-related adverse events (including cardiac arrhythmias) at 1 year
- trial originally designed to assess noninferiority of cryoballoon ablation for primary efficacy outcome, but conventional statistical analysis performed after noninferiority was met
- comparing cryoballoon ablation vs. radiofrequency ablation at 1 year
  - clinical failure in 34.6% vs. 35.9% (not significant)
  - primary safety outcome in 10.2% vs. 12.8% (not significant)
  - atrial flutter or atrial tachycardia in 0.8% vs. 2.7% (p = 0.09)
  - groin site complications in 1.9% vs. 4.3% (p = 0.09)
  - unresolved phrenic nerve injury at hospital discharge in 2.7% vs. 0% (p = 0.001)
- no significant differences in other adverse events including unresolved phrenic nerve injury at ≥ 3 months, cardiac tamponade or pericardial effusion, dyspnea, other nonarrhythmia cardiac complications, or pulmonary, transient neurologic, or gastrointestinal complications
- no atrioesophageal fistulae, pulmonary vein stenoses, or procedure-related deaths reported
- Reference – FIRE AND ICE trial (N Engl J Med 2016 Jun 9;374(23):2235)

cryoballoon ablation reported to achieve high rate of complete pulmonary vein isolation and to decrease recurrent atrial fibrillation at 1 year (level 3 [lacking direct] evidence)
- based on systematic review of mostly case series
- systematic review of 23 studies (mostly case series) evaluating cryoballoon ablation for paroxysmal and persistent atrial fibrillation
- blanking period defined as time frame during which transient episodes of arrhythmia were not considered recurrences
- 98.81% of patients (95% CI 97.88%-99.4%) achieved complete pulmonary vein isolation in analysis of 19 studies with 924 patients
- 98.47% of targeted veins (95% CI 98.03%-98.84%) were successfully isolated in analysis of 18 studies with 3,803 veins
- 72.83% of patients (95% CI 68.79%-76.62%) had 1-year freedom from recurrent paroxysmal atrial fibrillation in analysis of 5 studies with 3-month blanking period with 519 patients
- 60.34% of patients (95% CI 54.46%-66.02%) had 1-year freedom from recurrent paroxysmal atrial fibrillation in analysis of 3 studies without 3-month blanking period with 316 patients
- 45.16% of patients (95% CI 32.48%-58.32%) had 1-year freedom from recurrent persistent atrial fibrillation in analysis of 2 studies with 3-month blanking period with 62 patients
- Reference – Heart Rhythm 2011 Sep;8(9):1444, correction can be found in Heart Rhythm 2011 Nov;8(11):1828

cryoballoon catheter ablation may have similar freedom from atrial arrhythmia and persistent complications compared to open irrigated radiofrequency, but may have increased periprocedural complications in patients with paroxysmal atrial fibrillation (level 2 [mid-level] evidence)
- based on randomized noninferiority trial without blinding of outcome assessors
- 315 adults (median age 61 years, 60.6% men) in Germany with paroxysmal atrial fibrillation having pulmonary vein isolation randomized to cryoballoon catheter ablation vs. open irrigated radiofrequency ablation were followed for 12 months
  - only significant baseline difference was less vascular disease in cryoballoon group (2.6% vs. 8.2% in radiofrequency group, p = 0.028)
  - noninferiority criterion for efficacy defined as lower bound of 95% CI ≤ -15% for risk difference in absence of both atrial arrhythmia and persistent complications at 6 months and at 12 months
- persistent complications defined as any new pulmonary vein stenosis, phrenic nerve palsy, cerebrovascular accident, bleedings, or vascular complications during follow-up
- comparing cryoballoon catheter ablation vs. open irrigated radiofrequency ablation
  - absence of both atrial arrhythmia and persistent complications
    - at 6 months in 64.1% vs. 63.1% (risk difference 1%, 95% CI -9.7% to 11.6%, noninferiority met)
    - at 12 months in 73.6% vs. 70.7% (risk difference 2.9% 95% CI -7.4% to 13.2%, noninferiority met), increase in outcome a result of redo procedures, which were allowed after 6 months
  - periprocedural complications in 12.2% vs. 5% (p = 0.022, NNH 13), of which phrenic nerve palsy occurred in 5.8% vs. 0% but was transient
- Reference – FreezeAF trial (Circulation 2015 Oct 6;132(14):1311 full-text)

addition of intracardiac echocardiography to fluoroscopy may shorten procedure, fluoroscopy, and contrast times for cryoballoon ablation in atrial fibrillation (level 3 [lacking direct] evidence)
- based on small randomized trial without clinical outcomes
- 43 patients with paroxysmal atrial fibrillation having cryoballoon ablation for pulmonary vein isolation were randomized to addition of intracardiac echocardiography to fluoroscopy vs. fluoroscopy alone
- comparing intracardiac echocardiography plus fluoroscopy vs. fluoroscopy alone
  - recurrence of atrial fibrillation within 6 months in 27% vs. 33% (not significant)
  - mean length of procedure 130 minutes vs. 143 minutes (p = 0.05)
  - mean length of fluoroscopy 26 minutes vs. 42 minutes (p = 0.01)
  - mean amount of contrast used 88 mL vs. 169 mL (p
- Reference – J Cardiovasc Electrophysiol 2010 Nov;21(11):1202

Additional considerations

left atrial tissue fibrosis on delayed enhancement magnetic resonance imaging may predict recurrent arrhythmia at 1 year after first catheter ablation for paroxysmal and persistent atrial fibrillation (level 2 [mid-level] evidence)
- based on prognostic cohort study with inappropriate exclusion of patients
- 329 patients with paroxysmal and persistent atrial fibrillation had magnetic resonance imaging (MRI) prior to treatment with first catheter ablation
- 260 patients (mean age 59 years) included in analysis after excluding 57 patients (17%) due to poor MRI image quality and 12 patients (3.6%) due to loss to follow-up
  - 64% received antiarrhythmic treatment prior to ablation
  - left atrial tissue fibrosis was assessed using delayed enhancement MRI images up to 30 days prior to ablation
- mean follow-up after blanking period (90 days after ablation) was 255 days
- adjusted cumulative incidence of recurrent arrhythmia at 325 days after blanking period
  - 12% in 49 patients with stage 1 fibrosis (
  - 31% in 107 patients with stage 2 fibrosis (10%-19% of atrial wall)
  - 45% in 80 patients with stage 3 fibrosis (20%-29% of atrial wall)
  - 55% in 24 patients with stage 4 fibrosis (≥ 30% of atrial wall)
- consistent results at 475 days after blanking period
- each 1% increase in left atrial fibrosis associated with increased risk of recurrent arrhythmia (adjusted hazard ratio 1.06, 95% CI 1.03-1.09)
- Reference – DECAAF study (JAMA 2014 Feb 5;311(5):498), correction can be found in JAMA 2014 Nov 5, 2014; 312(17):1805

Procedural complications

0.1% mortality of 32,569 patients undergoing 45,115 atrial fibrillation ablation procedures worldwide between 1995 and 2006 in retrospective case series (J Am Coll Cardiol 2009 May 12;53(19):1798)

overall rate of periprocedural complications 2.6% in patients treated with catheter ablation from 2007 to 2012
- based on systematic review
- systematic review of 192 studies reporting incidence of periprocedural complication in 83,236 patients aged 51-77 years with atrial fibrillation treated with catheter ablation between 2000 and June 2012
- periprocedural complication in 2.6% of patients treated from 2007 to 2012 vs. 4% of patients treated from 2000 to 2006 (p = 0.003)
- rates of periprocedural complications from 2007 to 2012
  - vascular complications in 1.2%
  - tamponade in 0.9%
  - pericardial effusion in 0.7%
  - stroke in 0.55%
  - pulmonary vein stenosis in 0.4%
  - phrenic nerve injury in 0.4%
  - mortality 0.06%
- no significant differences in rates of complications among different ablation strategies
- Reference – Circ Arrhythm Electrophysiol 2013 Dec;6(6):1082

pulmonary vein stenosis
- incidence reported to decrease over time from 15.6% to 0.1%-0.29% with improvements in technique⁽³⁾
- radiofrequency catheter ablation of pulmonary veins associated with increased risk of pulmonary vein stenosis
  - based on retrospective cohort study
  - 335 patients having catheter ablation (of arrhythmogenic pulmonary veins or electrical isolation of all pulmonary veins) for drug-refractory atrial fibrillation
  - 18 (5%) had severe (> 70%) pulmonary vein stenosis at mean 5.2 months after ablation
  - 10 of these patients reported symptoms (dyspnea, cough, or hemoptysis)
  - Reference – Ann Intern Med 2003 Apr 15;138(8):634, commentary can be found in Curr Cardiol Rep 2003 Sep;5(5):348
- prevention may be achieved by avoidance of lesions within pulmonary valve⁽³⁾
  - techniques for improved visualization of pulmonary ostia to avoid pulmonary valve lesions include
    - intracardiac echocardiography
    - cardiac computed tomography
    - cardiac magnetic resonance imaging
  - visualization of microbubbles at catheter tip
atrial-esophageal fistula
- reported incidence 0.04%-0.2% in 2 cohort studies⁽³⁾
- frequently fatal⁽³⁾
- usually occurs 1-4 weeks after ablation^(1, 3)
- may present as
  - sudden neurologic symptoms due to esophageal air embolism^(1, 3)
  - acute inferior ischemia and/or heart block⁽¹⁾
- may be prevented with use of⁽³⁾
  - modification of catheter ablation energy settings
  - esophageal temperature monitoring
  - detection of microbubbles during catheter ablation
  - esophageal cooling devices
- case series of 9 patients can be found in Ann Intern Med 2006 Apr 18;144(8):572
cardiac tamponade⁽³⁾
- reported incidence 1.3% in 2 cohort studies
- related to catheter ablation energy settings
- may be identified with “pop” during ablation procedure
- small pericardial effusions may be treated conservatively but true tamponade is medical emergency
thromboembolic stroke⁽³⁾
- reported incidence of thromboembolism ranges from 0% to 7%⁽¹⁾
- may present during, within first week or more than 1 month after ablation procedure
- presence of left atrial spontaneous echocardiographic contrast (“smoke”) is major risk factor
- prevention strategies include
  - maintenance on therapeutic warfarin prior to procedure and use of intraprocedural anticoagulation (IV heparin or argatroban)
  - early identification of spontaneous echo contrast with echocardiography
phrenic nerve injury⁽³⁾
- reported incidence 0%-0.48%
- may present during the procedure and up to 6-7 days afterward
- 66% rate of recovery (J Am Coll Cardiol 2006 Jun 20;47(12):2498)
- phrenic nerve pacing may assist with prevention
vascular access site complications
- increased with use of more intensive anticoagulation protocols⁽³⁾
- reported incidence 0%-13%⁽¹⁾
- specific complications include⁽¹⁾
  - groin hematoma
  - retroperitoneal bleed
  - femoral arterial pseudoaneurysm
  - femoral arteriovenous fistula
other complications include
- left atrial edema⁽³⁾
- puncture of right atrium or aorta⁽³⁾
- peri-esophageal vagal nerve injury (pyloric spasm and gastroparesis)^(1, 3)
- acute coronary artery occlusion⁽¹⁾
- pericarditis⁽¹⁾
- mitral valve trauma⁽¹⁾
- vasoconstriction of right coronary artery and variant angina (Pacing Clin Electrophysiol 2007 Jan;30 Suppl 1:S98)
- atrial tachycardias
  - left atrial tachycardia (Pacing Clin Electrophysiol 2007 Jan;30 Suppl 1:S94)
  - focal atrial tachycardia (Heart Rhythm 2007 Mar;4(3 Suppl):S65)
  - organized atrial tachyarrhythmias (J Am Coll Cardiol 2007 Oct 30;50(18):1781)

Periprocedural medications

Anticoagulation recommendations

Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECAS)

preablation⁽¹⁾
- for patients in atrial fibrillation (AF) at time of procedure – use anticoagulation guidelines that pertain to cardioversion – if AF for ≥ 48 hours or for unknown duration, 3 weeks of systemic anticoagulation at therapeutic level recommended before procedure, or use transesophageal echocardiogram (TEE)
- catheter ablation of AF contraindicated if left atrial thrombus present
- consider catheter ablation of AF on patient who is therapeutically anticoagulated with warfarin – increased bleeding risk with change to heparin
during ablation⁽¹⁾
- give heparin before or immediately following transseptal puncture during AF ablation procedures and adjust to achieve and maintain an activated clotting time (ACT) of 300-400 seconds
- performance of AF ablation in a patient systemically anticoagulated with warfarin appears to be safe and does not alter need for IV heparin to maintain therapeutic ACT during procedure
- consider giving protamine following ablation to reverse heparin
postablation⁽¹⁾
- in patients who are not therapeutically anticoagulated with warfarin at time of AF ablation, use low-molecular-weight heparin (LMWH) or IV heparin as bridge to resumption of systemic anticoagulation with warfarin following AF ablation
- consider starting direct thrombin or factor Xa inhibitor after ablation as alternative postprocedure anticoagulation strategy
- consider reducing dose of LMWH (to 0.5 mg/kg twice daily) after procedure due to increased risk of bleeding on full dose LMWH
- systemic anticoagulation recommended for ≥ 2 months after ablation procedure
- decisions regarding continuation of systemic anticoagulation ≥ 2 months after ablation should be based on patient’s risk factors for stroke and not on presence or type of AF
- discontinuation of systemic anticoagulation therapy post ablation not recommended in patients at high risk of stroke (as estimated by currently recommended risk prediction scores, for example CHADS₂ or CHA₂DS₂VAS_C)
- consider continuous electrocardiographic monitoring to screen for asymptomatic atrial fibrillation/lone atrial fibrillation/atrial tachycardia if considering discontinuation of systematic anticoagulation

European Society of Cardiology (ESC)

when catheter ablation of atrial fibrillation is planned, consider continuation of oral anticoagulation with vitamin K antagonist during procedure, maintaining INR close to 2 (lower range of INR 2-2.5) (ESC Class IIa, Level B)⁽⁵⁾
- bridging therapy with heparin no longer recommended as it has risk for bleeding
- limited data with newer oral anticoagulants but they may be reasonable to use to avoid bridging therapy with heparin
continue oral anticoagulation for at least 3 months, then consider continuing or discontinuing oral anticoagulation based on individual stroke risk factors (ESC Class IIa, Level C)⁽⁴⁾
continuation of oral anticoagulation recommended if 1 major or ≥ 2 nonmajor risk factors (ESC Class IIa, Level B)⁽⁴⁾
- major risk factors
  - ≥ 75 years old
  - prior stroke, transient ischemic attack, or systemic embolism
- nonmajor risk factors
  - heart failure or left ventricular ejection fraction ≤ 40%
  - hypertension
  - diabetes mellitus
  - vascular disease
  - female gender
  - age 65-74 years

American College of Chest Physicians (ACCP)

American College of Chest Physicians (ACCP) guidelines (Ninth Edition) on antithrombotic therapy in atrial fibrillation
- all antithrombotic therapy recommendations for AF apply to patients with patients with AF being managed with a rhythm control strategy (pharmacologic or catheter ablation), regardless of apparent persistence of normal sinus rhythm (ACCP Grade 2C)
- Reference – Chest 2012 Feb;141(2 Suppl):e531S full-text or at National Guideline Clearinghouse 2012 Jun 4:35272
see Thromboembolic prophylaxis in atrial fibrillation for additional information

Anticoagulation efficacy

rivaroxaban may have similar effect on thromboembolism to vitamin K antagonists (VKAs) or dabigatran, and might decrease risk of major bleeding compared to VKAs, in patients having catheter ablation for atrial fibrillation (level 2 [mid-level] evidence)
- based on systematic review of mostly observational studies
- systematic review of 1 randomized trial and 7 observational studies comparing rivaroxaban vs. warfarin or dabigatran in patients having catheter ablation for atrial fibrillation
- review did not include follow-up study to ROCKET trial comparing rivaroxaban vs. warfarin in patients having subsequent cardioversion or catheter ablation because subgroup data for patients receiving catheter ablation not available
- comparing rivaroxaban to vitamin K antagonists (warfarin, fluindione, acecumarol
  - no significant difference in thromboembolism (stroke, transient ischemic attack, systemic or pulmonary embolism) in analysis of 7 studies with 3,575 patients
  - rivaroxaban associated with nonsignificantly lower risk of major bleeding (risk ratio 0.49, 95% CI 0.24-1.02) in analysis of 6 studies with 1,724 patients
- comparing rivaroxaban to dabigatran, no significant differences in
  - thromboembolism in analysis of 6 studies with 1,439 patients
  - major bleeding in analysis of 5 studies with 895 patients
- Reference – Am J Cardiol 2014 Aug 15;114(4):577

Corticosteroids

corticosteroids for 3 days after radiofrequency catheter ablation may decrease immediate and long-term atrial fibrillation recurrence (level 2 [mid-level] evidence)
- based on randomized trial with allocation concealment not stated
- 125 patients receiving pulmonary vein isolation for symptomatic paroxysmal atrial fibrillation randomized to corticosteroids (hydrocortisone 2 mg/kg IV on day of procedure and prednisone 0.5 mg/kg orally once daily for 3 days after procedure) vs. placebo
- comparing corticosteroids vs. placebo
  - immediate symptomatic atrial fibrillation recurrence (within 3 days) in 7% vs. 31% (p
  - early symptomatic atrial fibrillation recurrence (4-30 days) in 20% vs. 18% (not significant)
  - symptomatic atrial fibrillation recurrence at 14 months in 15% vs. 29% (p = 0.03, NNT 7)
- corticosteroid associated with lower body temperature and C-reactive protein levels in first 3 days (p
- Reference – J Am Coll Cardiol 2010 Oct 26;56(18):1463 full-text, editorial can be found in J Am Coll Cardiol 2010 Oct 26;56(18):1473

Antiarrhythmic drugs

commonly used for first 1-3 months after ablation⁽¹⁾
consider watch-and-wait rhythm control therapy when atrial fibrillation recurs within first 6 weeks after catheter ablation (ESC Class IIa, Level B)⁽⁵⁾

antiarrhythmic drugs may reduce atrial fibrillation-related events while on therapy (up to 90 days) but benefit may not persist after therapy discontinued (up to 1 year) (level 2 [mid-level] evidence)
- based on 3 randomized trials with baseline differences and methodologic limitations
- randomized trial with baseline differences
  - 2,038 adults (mean age 63 years, 75% men) had radiofrequency catheter ablation for atrial fibrillation (paroxysmal, persistent, or long lasting) and were randomized to Vaughan Williams class I or III antiarrhythmic drug vs. control for 90 days and followed for 1 year
  - antiarrhythmic drug and dosage determined according to Japanese atrial fibrillation guidelines (most commonly used were pilsicainide, flecainide, bepridil, and cibenzoline)
  - programming error in randomization system led to imbalances in many baseline factors
  - events defined as recurrent atrial tachyarrhythmias > 30 seconds or requiring repeat ablation, hospital admission, or usage of Vaughan Williams class I or III antiarrhythmic drug at 1 year
  - comparing antiarrhythmic drug vs. control
  - event-free survival at 90 days 59% vs. 52% (p = 0.01, NNT 15)
  - event-free survival at 1 year 70% vs. 68% (not significant)
  - Reference – EAST-AF trial (Eur Heart J 2016 Feb 14;37(7):610)
- randomized trial with allocation concealment not stated
  - 212 adults (median age 61 years, 83% men) having catheter ablation for atrial fibrillation (paroxysmal or persistent) randomized to amiodarone orally vs. placebo after ablation for 8 weeks and followed for 6 months
  - amiodarone 400 mg initiated on night of ablation, then 400 mg twice daily for 13 days, then 200 mg twice daily for 2 weeks, and then by 200 mg once daily for 4 weeks
  - recurrent atrial tachyarrhythmia (symptomatic or asymptomatic) lasting > 30 seconds comparing amiodarone vs. placebo
    - within 3 months in 34% vs. 53% (p = 0.006, NNT 6)
    - within 6 months in 39% vs. 48% (not significant)
  - Reference – AMIO-CAT trial (Eur Heart J 2014 Dec 14;35(47):3356), editorial can be found in Eur Heart J 2014 Dec 14;35(47):3321
- randomized trial and follow-up study without blinding
  - 110 patients (mean age 55 years) with paroxysmal atrial fibrillation having ablation were randomized to antiarrhythmic drug therapy vs. no antiarrhythmics for 6 weeks following ablation
  - primary endpoint was composite of
    - atrial arrhythmias lasting > 24 hours
    - atrial arrhythmias with symptoms requiring hospital admission, cardioversion, or initiation/change of antiarrhythmic drug therapy
    - intolerance to antiarrhythmic agent requiring drug cessation
  - comparing antiarrhythmic drug therapy vs. control
    - primary endpoint at 6 weeks in 19% vs. 42% (p = 0.005, NNT 5)
    - composite of atrial fibrillation > 24 hours, arrhythmia-related hospitalization, or cardioversion at 6 weeks in 13% vs. 28% (p = 0.05, NNT 7)
    - freedom from atrial fibrillation (including both symptomatic and asymptomatic events) at 6 months in 72% vs. 68% (not significant)
  - Reference – 5A trial (Circulation 2009 Sep 22;120(12):1036 full-text, Circ Arrhythm Electrophysiol 2011 Feb;4(1):11 full-text)

Proton pump inhibitors

commonly prescribed for up to 4 weeks to prevent esophageal ulceration but no data available to demonstrate reduction in incidence of development of atrial esophageal fistula⁽¹⁾

Antihypertensive medications

addition of moxonidine to standard antihypertensive treatment decreases atrial fibrillation recurrence after pulmonary vein isolation in patients with symptomatic drug-refractory paroxysmal atrial fibrillation and hypertension (level 1 [likely reliable] evidence)
- based on randomized trial
- 300 patients (mean age 60 years, 70% male) with symptomatic drug-refractory paroxysmal atrial fibrillation and hypertension having catheter ablation therapy with pulmonary vein isolation were randomized to moxonidine 0.2-0.4 mg/day orally vs. placebo starting 1 week before ablation
  - all patients had 3-month blanking period after ablation, during which patients presenting with atrial fibrillation for > 24 hours were pharmacologically or electrically cardioverted
  - all patients had concomitant standard antihypertensive therapy, class I or III antiarrhythmic drugs only allowed during blanking period
- median follow-up 13.7 months
- 97% included in analyses
- comparing moxonidine vs. placebo
  - atrial fibrillation recurrence after blanking period in 25.9% vs. 38.2% (p = 0.007, NNT 9)
  - mean recurrence-free survival 467 days vs. 409 days (p = 0.006)
- no significant differences between groups in blood pressure, death or all-cause hospitalization, or depression
- Reference – Circulation 2014 Oct 14;130(16):1346

use of renin-angiotensin-aldosterone modifier medication may not affect maintenance of sinus rhythm after ablation for atrial fibrillation (level 2 [mid-level] evidence)
- based on cohort study
- 419 patients who had catheter ablation for atrial fibrillation followed for median 1.7 years (range 0.9-5 years) after last procedure
- 142 patients were taking renin-angiotensin-aldosterone system (RAAS) modulators
- sinus rhythm maintained in 73.2% of patients taking RAAS modulators vs. 77.6% of patients not taking RAAS modulators (not significant)
- Reference – Europace 2010 Nov;12(11):1537 full-text, editorial can be found in Europace 2010 Nov;12(11):1509

Follow-up after catheter ablation

Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECAS) consensus recommendations on minimum follow-up screening recommendations⁽¹⁾
- for paroxysmal atrial fibrillation recurrence
  - 12-lead electrocardiogram (ECG) at each follow-up visit
  - 24-hour Holter at the end of the follow-up period (e.g. 12 months)
  - event recording regularly and at the time of symptoms with an event monitor from the end of the 3-month blanking period to the end of follow-up (such as, 12 months)
- for persistent or longstanding atrial fibrillation recurrence
  - 12-lead ECG at each follow-up visit
  - 24-hour Holter every 6 months
  - symptom-driven event monitoring
early recurrence (within 3 months of ablation)⁽¹⁾
- repeat ablation needed in 20%-40%
- because some early recurrences resolve spontaneously, defer repeat ablation for at least 3 months if possible
late recurrence (≥ 1 year)⁽¹⁾
- may occur in 11%-29% after single procedure, 7%-24% after repeat procedures
- predictors of late recurrence include
  - persistent atrial fibrillation
  - age
  - left atrial size
  - diabetes
  - valvular heart disease
  - nonischemic dilated cardiomyopathy

Surgical Ablation

Recommendations

Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECAS)

indications for concomitant surgical ablation of symptomatic AF in patients having surgery for other indications⁽¹⁾
- reasonable for patients with paroxysmal, persistent, or longstanding persistent AF refractory or intolerant to at least 1 class I or class III antiarrhythmic medication (HRS/EHRA/ECAS Class IIa, Level C)
- reasonable for patients with paroxysmal or persistent AF prior to starting antiarrhythmic drug therapy (HRS/EHRA/ECAS Class IIa, Level C)
- may be considered for patients with longstanding persistent AF prior to starting antiarrhythmic drug therapy (HRS/EHRA/ECAS Class IIb, Level C)
indications for stand-alone surgical ablation of symptomatic AF⁽¹⁾
- for patients with paroxysmal, persistent, or longstanding persistent AF refractory or intolerant to at least 1 class I or class III antiarrhythmic medication
  - may be considered for patients have failed ≥ 1 attempts at catheter ablation (HRS/EHRA/ECAS Class IIb, Level C)
  - may be considered for patients who have not failed catheter ablation but prefer a surgical approach (HRS/EHRA/ECAS Class IIb, Level C)
- NOT recommended prior to starting antiarrhythmic drug therapy (HRS/EHRA/ECAS Class III, Level C)

American College of Cardiology/American Heart Association (ACC/AHA)

reasonable for selected patients having cardiac surgery for other reasons (ACC/AHA Class IIa, Level C)⁽⁶⁾
may be reasonable as stand-alone procedure for selected patients with significant symptoms despite other management (ACC/AHA Class IIb, Level B)⁽⁶⁾

European Society of Cardiology (ESC)

consider surgical ablation of atrial fibrillation in patients with symptomatic atrial fibrillation having cardiac surgery (ESC Class IIa, Level A)⁽⁴⁾
surgical ablation of atrial fibrillation may be done in patients with asymptomatic atrial fibrillation having cardiac surgery if feasible with minimal surgical risk (ESC Class IIb, Level C)⁽⁴⁾
minimally invasive surgical ablation of atrial fibrillation without concomitant cardiac surgery is feasible and may be done for symptomatic atrial fibrillation after failure of catheter ablation (ESC Class IIb, Level C)⁽⁴⁾
in patients with hypertrophic cardiomyopathy and refractory atrial fibrillation, ablation procedures (with concomitant septal myectomy if indicated) may be considered (ESC Class IIa, Level C)⁽⁴⁾

Canadian Cardiovascular Society (CCS)

recommendations
- surgical ablation of atrial fibrillation recommended as adjuvant to cardiac surgery if (CCS Strong recommendation, Moderate-quality evidence with mitral valve surgery, CCS Conditional recommendation, Low-quality evidence with aortic valve surgery or coronary artery bypass surgery)
  - strong desire to maintain sinus rhythm
  - expected high success rate for maintaining sinus rhythm
  - low additional risk to surgical procedure
- closure (excision or obliteration) of left atrial appendage
  - recommended as part of surgical ablation of atrial fibrillation associated with mitral valve surgery (CCS Strong recommendation, Low-quality evidence)
  - suggested as part of surgical ablation of persistent atrial fibrillation in patients having aortic valve surgery or coronary artery bypass surgery if there is no increase in surgical risks (CCS Conditional recommendation, Low-quality evidence)
- surgical therapy for atrial fibrillation NOT recommended for patients with symptomatic lone atrial fibrillation (in whom atrial fibrillation is not expected to affect cardiac outcome) (CCS Strong recommendation, Low-quality evidence)
- continuation of oral anticoagulation after surgical ablation of atrial fibrillation
  - recommended in patients with CHADS₂ score ≥ 2 (CCS Strong recommendation, Moderate-quality evidence)
  - suggested in patients who have mechanical or bioprosthetic mitral valve replacement (CCS Conditional recommendation, Low-quality evidence)
- Reference – Can J Cardiol 2011 Jan-Feb;27(1):67

National Institute of Health and Care Excellence (NICE)

left atrial surgical ablation
- consider for patients with persistent atrial fibrillation refractory to medications
- may be considered for patients with symptomatic atrial fibrillation having cardiothoracic surgery for other indications
- discuss risk and benefits with patient prior to performing procedure
- Reference – NICE 2014 Jun:CG180 PDF

Cox-maze procedures

Cox-maze procedure is surgical placement of atrial incisions aimed at interrupting macro re-entrant circuits within atrial tissue (believed to be cause of atrial fibrillation) (J Thorac Cardiovasc Surg 1991 Apr;101(4):569), commentary can be found in J Thorac Cardiovasc Surg 1992 Nov;104(5):1491
Cox-maze IV procedure associated with similar effectiveness but less surgical time compared with Cox-maze III procedure (level 2 [mid-level] evidence)
- based on cohort study
- 242 patients who had Cox-maze procedure for atrial fibrillation were evaluated
  - 154 patients had Cox-maze III procedure which requires open-heart surgery (cut-and-sew technique)
  - 88 patients had Cox-maze IV procedure which requires use of bipolar radiofrequency energy and cryoablation as ablative sources to replace most incisions
- propensity analysis created comparison groups of 58 patients each who had either procedure
- comparing patients who had Cox-maze IV procedure vs. patients with Cox-maze III procedure
  - mean cross-clamp time 76 minutes vs. 121 minutes (p
  - no significant differences in
    - freedom from atrial fibrillation recurrence (> 90% in both groups at 1 year)
    - intensive care unit and hospital stay
    - 30-day mortality
    - permanent pacemaker placement
    - early atrial tachyarrhythmias
    - late stroke
    - survival
- Reference – J Thorac Cardiovasc Surg 2007 Feb;133(2):389

Efficacy of surgical ablation

surgical ablation appears to increase freedom from atrial fibrillation, but does not appear to affect mortality (level 2 [mid-level] evidence)
- based on systematic review of observational studies
- systematic review of 69 studies evaluating biatrial and left atrial surgical ablation for treatment of atrial fibrillation in 5,885 patients
  - 75% of studies were retrospective
  - 42% of studies had
- data pooled from different studies to compare surgical patients vs. control patients, data from direct comparative studies not reported
- surgical ablation associated with
  - freedom from atrial fibrillation at 1 year in 84.5% patients based on 37 studies with 3,225 patients
  - freedom from atrial fibrillation at 3 years in 85.4% patients based on 18 studies with 1,801 patients
  - 1-year survival rate 94.5% based on 52 studies with 3,841 patients
  - 3-year survival rate 92.5% based on 17 studies with 1,338 patients
- control group associated with
  - freedom from atrial fibrillation at 1 year in 30.8% patients based on 10 studies with 312 patients
  - freedom from atrial fibrillation at 3 years in 60.9% patients based on 6 studies with 514 patients
  - 1-year survival rate 97.8% based on 11 studies with 429 patients
  - 3-year survival rate 95.1% based on 6 studies with 334 patients
- Reference – J Thorac Cardiovasc Surg 2006 May;131(5):1029, commentary can be found in J Thorac Cardiovasc Surg 2006 May;131(5):949

surgical ablation may increase sinus rhythm and decrease pericardial tamponade but may have no effect on mortality in patients with atrial fibrillation having cardiac surgery (level 2 [mid-level] evidence)
- based on systematic review of trials with methodologic limitations
- systematic review of 16 randomized trials comparing surgical ablation vs. no surgical ablation for treatment of atrial fibrillation in 1,082 patients having cardiac surgery
- most trials had ≥ 1 limitation including
  - unclear or inadequate allocation concealment
  - unclear or lack of blinding
- surgical ablation associated with
  - increase in sinus rhythm at ≥ 12 months in analysis of all trials
    - odds ratio 6.7 (95% CI 4.88-9.22)
    - increase in normal sinus rhythm also at 3 months and 6 months
  - decreased pericardial tamponade (odds ratio 0.25, 95% CI 0.078-0.82) in analysis of 5 trials
- no significant differences in mortality, pacemaker implantation, and neurological events
- Reference – Heart 2014 May;100(9):722

Comparative efficacy of surgical vs. catheter ablation

surgical ablation may be as effective as radiofrequency-microwave or cryoablation for conversion to sinus rhythm in patients with atrial fibrillation (level 3 [lacking direct] evidence)
- based on systematic review of trials with baseline differences and without clinical outcomes
- systematic review of 48 trials evaluating energy-related ablation (radiofrequency-microwave and cryoablation) in 2,279 patients vs. surgical ablation for treatment of atrial fibrillation in 1553 patients
- at baseline, surgical ablation group had significantly younger patients (p = 0.005) and significantly more patients with lone (p = 0.06) or paroxysmal (p = 0.05) atrial fibrillation
- comparing surgical ablation vs. energy ablation, conversion to sinus rhythm not significantly different
- Reference – Eur J Cardiothorac Surg 2005 Feb;27(2):258, commentary can be found in Evid Based Cardiovasc Med 2005 Jun;9(2):120, Eur J Cardiothorac Surg 2005 Jul;28(1):183
surgical ablation may be more effective than catheter ablation for reducing left atrial arrhythmia (level 3 [lacking direct] evidence) but associated with more procedural adverse events (level 2 [mid-level] evidence) in patients with atrial fibrillation refractory to antiarrhythmic drugs
- based on randomized trial without blinding
- 129 patients aged 30-70 years with atrial fibrillation and refractory to antiarrhythmic drugs were randomized to minimally invasive surgical ablation vs. catheter ablation and followed for 12 months
- 67% patients had prior failed catheter ablation, 33% had left atrial dilatation and hypertension
- 124 patients (96%) completed trial and analyzed
- comparing minimally invasive surgical ablation vs. catheter ablation
  - freedom from left atrial arrhythmia > 30 seconds (on 7-day Holter recording) without antiarrhythmic drugs at 12 months in 65.6% vs. 36.5% (p = 0.0022, NNT 4)
  - procedural adverse events in 23% vs. 3.2% (p = 0.001, NNH 5)
  - median duration of hospitalization 5.5 days vs. 2 days (p
- adverse events in > 1 surgical ablation patients
  - pneumothorax in 6 (10%) patients
  - pacemaker implant in 2 (3%) patients
- Reference – FAST trial (Circulation 2012 Jan 3;125(1):23), commentary can be found in Nat Rev Cardiol 2011 Dec 6;9(2):68

Addition of Ablation to Cardiac Surgery

addition of atrial fibrillation ablation to mitral valve surgery with closure of left atrial appendage appears to reduce atrial fibrillation but may increase risk of permanent pacemaker implantation (level 1 [likely reliable] evidence)
- based on randomized trial with allocation concealment not stated
- 260 patients (mean age 69 years) with persistent atrial fibrillation (AF) having mitral valve surgery were randomized intraoperatively to surgical ablation of AF vs. no ablation and followed for 1 year
  - absence of left atrial thrombus was confirmed by intraoperative echocardiography prior to randomization
  - surgical ablation group further randomized to pulmonary vein isolation vs. biatrial maze procedure
  - all patients had closure of left atrial appendage
- 54% had long-standing persistent AF defined as continuous AF for > 12 months, and 46% had persistent AF defined as non-self-terminating AF for ≥ 7 days or for
- outcome assessors were blinded
- comparing surgical ablation vs. no ablation
  - freedom from AF at 6 and 12 months in 63.2% vs. 29.4% (p
  - rate of permanent pacemaker implantation for conduction abnormality 21.5 vs. 8.1 per 100 patient-years (p = 0.01)
  - major cardiac or cerebrovascular adverse events in 23.3% vs. 20.5% (not significant)
  - mortality 6.8% vs. 8.7% (not significant)
- no significant differences in overall rate of serious adverse events or in physical or mental function at 1 year
- no significant difference in freedom from AF comparing pulmonary vein isolation vs. biatrial maze procedure
- Reference – N Engl J Med 2015 Apr 9;372(15):1399, editorial can be found in N Engl J Med 2015 Apr 9;372(15):1465
addition of left atrial ablation to cardiac surgery may not decrease risk of death, heart failure, bleeding, or stroke at 1 year in patients with heart disease and atrial fibrillation (level 2 [mid-level] evidence)
- based on randomized trial with allocation concealment not stated
- 224 patients (mean age 70 years) with atrial fibrillation plus coronary and/or valve disease were randomized to cardiac surgery with left atrial ablation vs. cardiac surgery without left atrial ablation and followed for 1 year
- follow-up at 1 year in 91% for complications and in 75% for electrocardiogram assessment
- comparing surgery with ablation vs. surgery without ablation at 1 year
  - mortality in 16.2% vs. 17.4% (not significant)
  - heart failure in 23.4% vs. 26.1% (not significant)
  - combined death, bleeding, stroke, or heart failure in 40.5% vs. 40.2% (not significant)
  - sinus rhythm without atrial fibrillation during 24-hour electrocardiogram in 60.2% vs. 35.5% (p = 0.002, NNT 4)
- no significant differences at 30 days in mortality, myocardial ischemia, stroke, renal failure, or all combined
- Reference – PRAGUE-12 trial (Eur Heart J 2012 Nov;33(21):2644 full-text)
addition of surgical ablation to valvular and/or coronary bypass surgery may not improve health-related quality of life in patients with atrial fibrillation (level 2 [mid-level] evidence)
- based on randomized trial with inadequate statistical power
- 150 patients (mean age 68 years) with atrial fibrillation were randomized to cardiac surgery plus surgical ablation therapy vs. cardiac surgery alone
- both groups had improved health-related quality of life scores, no significant differences between groups
- conversion to sinus rhythm in 57.1% with surgical ablation vs. 41.9% without (not significant)
- Reference – J Cardiovasc Electrophysiol 2010 May;21(5):511
addition of epicardial left atrial cryoablation during mitral valve surgery may be associated with higher rate of sinus rhythm in patients with atrial fibrillation (level 3 [lacking direct] evidence)
- based on randomized trial without clinical outcomes
- 69 patients with permanent atrial fibrillation randomized to mitral valve surgery with vs. without epicardial left atrial cryoablation
- comparing cryoablation vs. no cryoablation
  - sinus rhythm at 6 months in 73.3% vs. 45.7% (p = 0.024, NNT 4)
  - sinus rhythm at 12 months in 73.3% vs. 42.9% (p = 0.013, NNT 4)
  - in-hospital complication rate 26.5% vs. 11.4% (not significant)
- Reference – SWEDMAF study (Eur Heart J 2007 Dec;28(23):2902 full-text)
addition of Cox Maze ablation procedure to valvular surgery decreases recurrence of atrial fibrillation compared to delayed circumferential pulmonary vein isolation (CPVI) in patients with atrial fibrillation and rheumatic heart disease (level 3 [lacking direct] evidence)
- based on randomized trial without clinical outcomes
- 106 patients with long-lasting persistent atrial fibrillation and rheumatic heart disease randomized to valvular surgery with concomitant Cox Maze procedure vs. valvular surgery with CPVI and substrate modification 6 months after surgery
- Cox Maze III procedure used Saline-Irrigated Cooled-Tip Radiofrequency Ablation (SICTRA) system
- 99 patients available for analysis at mean follow-up 20 months with Maze procedure vs. 15 months with CPVI
- comparing Maze procedure vs. CPVI
  - free of asymptomatic or symptomatic arrhythmia 12 months after 1 procedure in 82% vs. 55.2% (p
  - atrial fibrillation-free survival at end of follow-up 88% vs. 71% (p
- no significant difference in complication rates
- Reference – Eur Heart J 2010 Nov;31(21):2633 full-text, editorial can be found in Eur Heart J 2010 Nov;31(21):2572 full-text
radiofrequency ablation of left atrium for atrial fibrillation in patients undergoing mitral valve surgery increased rate of sinus rhythm at 1 year (level 3 [lacking direct] evidence)
- based on randomized trial without clinical outcomes
- 97 patients referred for mitral valve surgery with at least 6 months of continuous atrial fibrillation randomized to mitral valve surgery and radiofrequency ablation of left atrium vs. mitral valve surgery alone
- comparing radiofrequency ablation group vs. control group
  - sinus rhythm without pacemaker at hospital discharge in 53.3% vs. 4.5% (p
  - 12-month outcomes
    - sinus rhythm without pacemaker in 44.4% vs. 4.5% (p
    - no significant differences in
      - mean shuttle-walk distance 359 meters vs. 304 meters
      - New York Heart Association (NYHA) class
- Reference – JAMA 2005 Nov 9;294(18):2323, editorial can be found in JAMA 2005 Nov 9;294(18):2357
postoperative continuous overdrive biatrial pacing may reduce length of hospitalization (level 2 [mid-level] evidence) and early recurrence of atrial fibrillation (level 3 [lacking direct] evidence) in patients having valve surgery plus full Maze procedure
- based on randomized trial with allocation concealment not stated
- 100 patients (mean age 56 years) having mitral valve and/or tricuspid valve surgery plus full Maze procedure randomized to postoperative continuous overdrive biatrial pacing for 5 days vs. no pacing
- comparing pacing vs. no pacing
  - mean length of hospitalization 6.1 days vs. 8.7 days (p
  - mean length of stay in intensive care unit 2.1 days vs. 3.6 days (p
  - recurrent postoperative atrial fibrillation in 12% vs. 36% (p
- Reference – J Thorac Cardiovasc Surg 2011 Nov;142(5):989

Atrioventricular (AV) Nodal Ablation

Recommendations

American College of Cardiology/American Heart Association (ACC/AHA)

ablation therapy for rate control⁽⁶⁾
- AV nodal ablation should not be attempted unless previous trial of medical therapy has failed to adequately control heart rate (ACC/AHA Class III, Level C)
- ablation of AV node or accessory pathway may be indicated when medical therapy fails to control heart rate or produces intolerable side effects (ACC/AHA Class IIa, Level B)
- catheter-directed AV nodal ablation may be indicated when heart rate cannot be controlled pharmacologically or tachycardia-mediated cardiomyopathy is suspected (ACC/AHA Class IIb, Level C)
catheter ablation of the accessory pathway recommended in symptomatic patients with atrial fibrillation with Wolff-Parkinson-White (WPW) preexcitation syndrome, particularly if the accessory pathway may permit rapid antegrade conduction due to a short refractory period (ACC/AHA Class I, Level C)⁽⁶⁾

European Society of Cardiology (ESC)

do not attempt catheter ablation of AV node without prior trial of medication or catheter ablation of atrial fibrillation (ESC Class III, Level C)⁽⁴⁾
consider AV node ablation for rate control when (ESC Class IIa, Level B)⁽⁴⁾
- rate cannot be controlled by drugs
- atrial fibrillation cannot be prevented by antiarrhythmic therapy or is associated with intolerable side effects
- direct catheter-based or surgical ablation of atrial fibrillation is not indicated, has failed or is rejected
consider AV node ablation for patients with permanent atrial fibrillation and indication for cardiac resynchronization therapy (ESC Class IIa, Level B)⁽⁴⁾
- New York Heart Association (NYHA) functional class III or ambulatory class IV symptoms despite optimal medical therapy
- left ventricular ejection fraction ≤ 35%
- QRS width ≥ 130 milliseconds
consider AV node ablation for cardiac resynchronization therapy nonresponders if atrial fibrillation prevents effective biventricular stimulation and amiodarone is ineffective or contraindicated (ESC Class IIa, Level C)⁽⁴⁾
consider AV node ablation for suspected tachycardia-mediated cardiomyopathy if rate control with drugs not indicated, failed, or rejected (ESC Class IIb, Level C)⁽⁴⁾
consider AV node ablation then cardiac synchronization therapy in patients with permanent atrial fibrillation, left ventricular ejection fraction ≤ 35%, NYHA class I or II symptoms on optimal medical therapy and rate control therapy insufficient or intolerable (ESC Class IIb, Level C)⁽⁴⁾
considerations for pacemaker implantation after AV node ablation⁽⁴⁾
- consider biventricular stimulation after AV node ablation if left ventricular ejection fraction ≤ 35% or severe heart failure symptoms (ESC Class IIa, Level C)
- consider cardiac resynchronization therapy pacemaker for any type of atrial fibrillation if moderately depressed left ventricular function (≤ 45%) and mild heart failure symptoms (NYHA II) (ESC Class IIb, Level C)
- consider dual-chamber (DDD) pacemaker with mode-switch function if paroxysmal atrial fibrillation and normal left ventricular function (ESC Class IIb, Level C)
- consider single-chamber (VVIR) pacemaker if persistent or permanent atrial fibrillation and normal left ventricular function (ESC Class IIb, Level C)

Canadian Cardiovascular Society (CCS)

AV junction ablation and implantation of a permanent pacemaker recommended in symptomatic patients with uncontrolled ventricular rates during atrial fibrillation despite maximally tolerated combination pharmacologic therapy (CCS Strong recommendation, Moderate-quality evidence)
Reference – Can J Cardiol 2011 Jan-Feb;27(1):47, correction can be found in Can J Cardiol 2011 May-Jun;27(3):388

National Institute of Health and Care Excellence (NICE)

atrioventricular node ablation and pacing
- consider for patients with symptomatic permanent atrial fibrillation or left ventricular dysfunction likely caused by high ventricular rate
- following procedure, reassess symptoms, need for secondary ablation, and optimization of any medications
- Reference – NICE 2014 Jun:CG180 PDF

AV node ablation in lone atrial fibrillation

AV junction ablation and pacing may improve quality of life, symptoms, and overall activity compared to medication therapy in patients with chronic lone atrial fibrillation (AF) and normal ventricular response (level 2 [mid-level] evidence)
- based on cohort study
- 50 patients with chronic lone AF and normal ventricular rate treated with AV junction ablation and pacemaker insertion or continuation of medical therapy according to patient choice and followed for 12 months
- 21 patients had AV node ablation, 29 patients treated with medical therapy
- AV node ablation associated with
  - improvement in quality of life score (p
  - decrease in overall symptoms (p
  - decrease in limitation of activity (p
- Reference – J Cardiovasc Electrophysiol 2001 Mar;12(3):303, editorial can be found in J Cardiovasc Electrophysiol 2001 Mar;12(3):310
radiofrequency ablation of AV node and implantation of permanent pacemaker in patients with lone atrial fibrillation reported to be associated with long-term survival similar to general population (level 3 [lacking direct] evidence)
- based on subgroup analysis of cohort study
- 350 patients who had AV node ablation and implantation of permanent pacemaker for refractory AF compared with 2 control populations
- none of 26 patients who had lone AF died during mean follow-up of 37 months
- Reference – N Engl J Med 2001 Apr 5;344(14):1043

AV node ablation in patients with heart failure having cardiac resynchronization therapy (CRT)

atrioventricular nodal ablation may improve survival compared to drug therapy in patients with heart failure receiving cardiac resynchronization therapy (level 2 [mid-level] evidence)
- based on 2 cohort studies
- 154 patients with atrial fibrillation and heart failure had atrioventricular nodal ablation or drug therapy for rate control during cardiac resynchronization therapy (CRT)
  - comparing atrioventricular nodal ablation vs. drug therapy
    - 2-year survival 96% vs.76.5% (p = 0.008)
    - greater improvement in New York Heart Association (NYHA) Class (p = 0.04)
    - no significant differences in left ventricular ejection fraction or left ventricular end-diastolic diameter
  - Reference – Heart Rhythm 2010 Sep;7(9):1240
- 243 patients with heart failure and permanent atrial fibrillation had CRT and either atrioventricular junction ablation or negative chronotropic drugs
  - median follow-up 34 months
  - compared with pharmacologic rate control, atrioventricular junction ablation associated with
    - decreased mortality rate (adjusted hazard ratio [HR] 0.26, 95% CI 0.09-0.73)
    - decreased cardiac mortality rate (adjusted HR 0.31, 95% CI 0.10-0.99)
    - decreased heart failure mortality rate (adjusted HR 0.15, 95% CI 0.03-0.70)
  - Reference – Eur Heart J 2008 Jul;29(13):1644 full-text, commentary can be found in Eur Heart J 2008 Sep;29(17):2182 full-text
atrioventricular junction ablation may increase cardiac mortality risk for heart failure patients with atrial fibrillation treated with CRT (level 2 [mid-level] evidence)
- based on subgroup analysis of retrospective cohort study
- 131 patients with heart failure and CRT reviewed
- 53 patients with atrial fibrillation and heart failure reviewed (26 had A-V nodal ablation, 27 did not)
- compared with no ablation, atrioventricular junction ablation group had increased cardiac mortality risk (hazard ratio 5.22, 95% CI 1.6-17.01)
- Reference – Europace 2008 Jul;10(7):809 full-text, editorial can be found in Europace 2008 Jul;10(7):779 full-text
atrioventricular junction ablation may increase rate of resumption of sinus rhythm in patients with permanent atrial fibrillation having CRT (level 3 [lacking direct] evidence)
- based on retrospective cohort study without clinical outcomes
- 330 heart failure patients with atrial fibrillation and CRT treatment reviewed
- 10% had sinus rhythm resumption after CRT at median 4 months
- atrioventricular junction ablation associated with increased rate of resumption of sinus rhythm (hazard ratio 4.27, 95% CI 1.54-11)
- Reference – Eur Heart J 2010 Apr;31(8):976 full-text
atrioventricular junction ablation reported to be associated with improvements in ejection fraction and exercise performance in heart failure patients with permanent atrial fibrillation treated with CRT (level 3 [lacking direct] evidence)
- based on cohort study without clinical outcomes
- cohort of patients with heart failure and ventricular conduction disturbances receiving CRT included
  - 48 patients with permanent atrial fibrillation with ventricular rate controlled by drugs, apparent biventricular pacing > 85% of pacing time
  - 114 patients with permanent atrial fibrillation who had atrioventricular junction ablation, 100% resynchronization therapy delivery
- atrial fibrillation patients treated with atrioventricular junction ablation had significant improvements in ejection fraction, exercise tolerance (6-minute walk test or symptom limited peak O₂ consumption during exercise), and reverse remodeling effect
- patients treated with pharmacologic rate control not associated with significant improvements on outcomes
- Reference – J Am Coll Cardiol 2006 Aug 15;48(4):734, editorial can be found in J Am Coll Cardiol 2006 Aug 15;48(4):744
optimized echo-guided cardiac resynchronization therapy (CRT) reduces worsening heart failure compared to conventional right ventricular pacing in heart failure patients having atrioventricular junction ablation for permanent atrial fibrillation (level 1 [likely reliable] evidence)
- based on randomized trial
- 186 patients with successful atrioventricular junction ablation and CRT device implantation were randomized to optimized echo-guided CRT vs. right ventricular apical pacing
- median follow-up 20 months
- comparing echo-guided CRT vs. right ventricular apical pacing
  - worsening heart failure (leading to symptoms and signs, hospitalization, or death) in 11% vs. 26% (p = 0.005, NNT 7 for CRT)
  - death from heart failure in 3.1% vs. 4.5% (not significant)
  - hospitalization due to heart failure in 3 patients (7 hospitalizations) vs. 12 patients (15 hospitalizations) (p = 0.013)
- Reference – Eur Heart J 2011 Oct;32(19):2420 full-text, editorial can be found in Eur Heart J 2011 Oct;32(19):2344 full-text

Ablation of Accessory Pathway

Recommendations

American College of Cardiology/American Heart Association (ACC/AHA)

ablation of atrioventricular (AV) node or accessory pathway may be indicated when medical therapy fails to control heart rate or produces intolerable side effects (ACC/AHA Class IIa, Level B) (Circulation 2006 Aug 15;114(7):e257 full-text)
catheter ablation of the accessory pathway recommended in symptomatic patients with atrial fibrillation with Wolff-Parkinson-White (WPW) preexcitation syndrome, particularly if the accessory pathway may permit rapid antegrade conduction due to a short refractory period (ACC/AHA Class I, Level C)⁽⁶⁾

European Society of Cardiology (ESC)

in patients with Wolff-Parkinson-White syndrome⁽⁴⁾
- catheter ablation of an overt accessory pathway recommended in patients with atrial fibrillation to prevent sudden cardiac death (ESC Class I, Level A)
- immediate referral for catheter ablation recommended in survivors of sudden cardiac death with overt accessory pathway conduction (ESC Class I, Level C)
- catheter ablation recommended for patients with asymptomatic overt accessory pathway conduction on surface electrocardiogram (ECG) if
  - high-risk profession such as pilot or public transport driver (ESC Class I, Level B)
  - high risk of developing atrial fibrillation (ESC Class I, Level B)
- consider catheter ablation in patients with asymptomatic overt accessory pathway conduction only after full explanation and careful counselling (ESC Class IIa, Level B)

Canadian Cardiovascular Society (CCS)

catheter ablation of accessory pathway recommended in patients with evidence of ventricular preexcitation during atrial fibrillation, especially if atrial fibrillation associated with rapid ventricular rate, syncope, or pathway with short refractory period (CCS Strong recommendation, Low-quality evidence)
in young patients with lone paroxysmal atrial fibrillation, electrophysiological study suggested to exclude reentrant tachycardia as cause of atrial fibrillation (and curative ablation suggested if present) (CCS Conditional recommendation, Very Low-quality evidence)
Reference – Can J Cardiol 2011 Jan-Feb;27(1):60

Quality Improvement

Physician Quality Reporting System Quality Measures

392. HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
- Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is reported as four rates stratified by age and gender. Reporting Age Criteria:
  - Females 18-64 years old
  - Males 18-64 years old
  - Females ≥ 65 years old
  - Males ≥ 65 years old

Choosing Wisely

Heart Rhythm Society recommends against ablating the atrioventricular node in patients with atrial fibrillation when both symptoms and heart rate are acceptably controlled by well-tolerated medical therapy (Choosing Wisely 2014 Feb 10)

Guidelines and Resources

Guidelines

see Atrial fibrillation for additional guidelines

International guidelines

Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECAS) expert consensus statement on catheter and surgical ablation of atrial fibrillation can be found in Heart Rhythm 2012 Apr;9(4):632 PDF or at National Guideline Clearinghouse 2013 May 6:39247, or in Europace 2012 Apr;14(4):528 full-text

Venice Chart international consensus document on atrial fibrillation ablation can be found in J Cardiovasc Electrophysiol 2012 Aug;23(8):890

United States guidelines

American College of Cardiology/American Heart Association (ACC/AHA) guideline on management of patients with atrial fibrillation can be found in Circulation 2014 Dec 2;130(23):e199 full-text, also published in J Am Coll Cardiol 2014 Dec 2;64(21):e1 full-text, corrections can be found in Circulation 2014 Dec 2;130(23):e272 and J Am Coll Cardiol 2014 Dec 2;64(21):2305, previous versions can be found in Circulation 2006 Aug 15;114(7):e257 full-text (correction can be found in Circulation 2007 Aug 7;116(6):e138), Circulation 2011 Jan 4;123(1):104 full-text (correction can be found in Circulation 2011 Aug 2;124(5):e173), Circulation 2013 May 7;127(18):1916 full-text

American College of Cardiology/American Heart Association (ACC/AHA) guideline on clinical intracardiac electrophysiological and catheter ablation procedures can be found in J Am Coll Cardiol 1995 Aug;26(2):555

United Kingdom guidelines

National Institute for Health and Care Excellence (NICE) guideline on management of atrial fibrillation can be found at NICE 2014 Jun:CG180 PDF or at National Guideline Clearinghouse 2014 Sep 8:48333, summary can be found in BMJ 2014 Jun 19;348:g3655 (correction can be found in BMJ 2014;349:g4440)

Canadian guidelines

Canadian Cardiovascular Society (CCS)
- focused 2014 update of CCS atrial fibrillation guidelines: management of atrial fibrillation can be found in Can J Cardiol 2014 Oct;30(10):1114
- focused 2012 update of CCS atrial fibrillation guidelines: recommendations on stroke prevention and rate/rhythm control can be found in Can J Cardiol 2012 Mar-Apr;28(2):125, correction can be found in Can J Cardiol 2012 May;28(3):396
- CCS 2010 atrial fibrillation guidelines on
  - etiology and initial investigations can be found in Can J Cardiol 2011 Jan-Feb;27(1):31
  - management of recent-onset atrial fibrillation and flutter in emergency department can be found in Can J Cardiol 2011 Jan-Feb;27(1):38
  - rate and rhythm management can be found in Can J Cardiol 2011 Jan-Feb;27(1):47
  - catheter ablation for atrial fibrillation/atrial flutter can be found in Can J Cardiol 2011 Jan-Feb;27(1):60
  - surgical therapy can be found in Can J Cardiol 2011 Jan-Feb;27(1):67
  - prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter can be found in Can J Cardiol 2011 Jan-Feb;27(1):74
  - prevention and treatment of atrial fibrillation following cardiac surgery can be found in Can J Cardiol 2011 Jan-Feb;27(1):91

European guidelines

European Society of Cardiology (ESC) guideline on management of atrial fibrillation can be found in Eur Heart J 2010 Oct;31(19):2369 full-text, correction can be found in Eur Heart J. 2011 May;32(9):1172, also published in Europace 2010 Oct;12(10):1360 full-text, correction can be found in Europace 2011 Jul;13(7):1058
- focused update can be found in Eur Heart J 2012 Nov;33(21):2719 full-text, correction can be found in Eur Heart J 2013 Mar;34(10):790, Eur Heart J 2013 Sep;34(36):2850, also published in Europace 2012 Oct;14(10):1385 full-text, commentary can be found in Europace 2013 Mar;15(3):460 full-text

Asian guidelines

Japanese Circulation Society (JCS) guideline on nonpharmacological therapy of cardiac arrhythmias can be found at JCS 2013 PDF [Japanese 日本語]

Australian and New Zealand guidelines

National Heart Foundation of Australia consensus statement on catheter ablation as therapy for atrial fibrillation can be found in Med J Aust 2013 Jan 21;198(1):27

Review articles

review of catheter ablation of atrial arrhythmias can be found in Lancet 2012 Oct 27;380(9852):1509
Canadian Agency for Drugs and Technologies in Health (CADTH) Technology Overview on ablation procedures for rhythm control in patients with atrial fibrillation can be found at CADTH 2012 Aug PDF
review of catheter ablation of atrial fibrillation can be found in Circ J 2011 Sep 22;75(10):2305
review of outcomes of ablation of longstanding persistent atrial fibrillation can be found in Heart Rhythm 2010 Jun;7(6):835
review of radiofrequency ablation for atrial fibrillation can be found in BMJ 2001 Mar 31;322(7289):777 full-text
review of catheter ablation of supraventricular arrhythmias and atrial fibrillation can be found in Am Fam Physician 2009 Nov 15;80(10):1089 full-text
review of catheter ablation therapy for supraventricular arrhythmias can be found in JAMA 2007 Dec 19;298(23):2768
review of radiofrequency ablation for cardiac arrhythmias can be found in N Engl J Med 1999 Feb 18;340(7):534
editorial supporting catheter ablation of cardiac arrhythmias can be found in BMJ 2000 Sep 23;321(7263):716 full-text, commentary can be found in BMJ 2001 Mar 10;322(7286):613
review of management of lone atrial fibrillation can be found in Eur J Cardiothorac Surg 2012 Jun;41(6):1284
review of surgical ablation techniques performed as an additional treatment during otherwise indicated cardiac surgery can be found in Cardiol Res Pract. 2012;2012:149503 full-text
review with focus on invasive treatments for atrial fibrillation can be found in Adv Stud Med 2006 Jun;6(6):275 PDF
discussion of nonpharmacologic treatments for atrial fibrillation can be found in Adv Stud Med 2006 Sep;6(8):351 PDF
review of surgical treatment of atrial fibrillation can be found in World J Surg 2008 Mar;32(3):346
case presentations
- catheter ablation for atrial fibrillation can be found in N Engl J Med 2011 Dec 15;365(24):2296
- pulmonary vein stenosis as complication of ablation can be found in
  - N Engl J Med 2006 Mar 2;354(9):957, commentary can be found in N Engl J Med 2006 May 25;354(21):2289
  - BMJ 2008 Apr 12;336(7648):830 full-text

MEDLINE search

to search MEDLINE for (Atrial fibrillation AND ablation) with targeted search (Clinical Queries for therapy articles), click here

Patient Information

information on atrial fibrillation/pulmonary vein ablation procedure from NYU Cardiac and Vascular Institute
information on multiple ablation procedures from StopAfib.org

ICD-9/ICD-10 Codes

ICD-9 codes

427.31 atrial fibrillation

ICD-10 codes

I48 atrial fibrillation and flutter

References

General references used

1. Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace. 2012 Apr;14(4):528-606 full-text or in Heart Rhythm 2012 Apr;9(4):632
2. Pappone C, Santinelli V. Atrial Fibrillation Ablation. Rev Esp Cardiol. 2012 Jun;65(6):560-569
3. Maan A, Shaikh AY, Mansour M, Ruskin JN, Heist EK. Complications from catheter ablation of atrial fibrillation: a systematic review. Crit Pathw Cardiol. 2011 Jun;10(2):76-83
4. European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010 Oct;31(19):2369-429 full-text
5. Camm AJ, Lip GY, De Caterina R et al; ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012 Nov;33(21):2719-47, correction can be found in Eur Heart J 2013 Mar;34(10):790 full-text, also published in Europace 2012 Oct;14(10):1385
6. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130(23):e199-267 PDF, also published in J Am Coll Cardiol 2014 Dec 2;64(21):e1, corrections can be found in Circulation 2014 Dec 2;130(23):e272 and J Am Coll Cardiol 2014 Dec 2;64(21):2305

Recommendation grading systems used

American College of Cardiology/American Heart Association (ACC/AHA) and Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECAS) use same grading system for guidelines
- classifications of recommendations
  - Class I – procedure or treatment should be performed or administered
  - Class IIa – reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
  - Class IIb – procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
  - Class III – procedure or treatment should not be performed or administered because it is not helpful or may be harmful
    - Class III ratings may be subclassified as Class III No Benefit or Class III Harm
- levels of evidence
  - Level A – data derived from multiple randomized clinical trials or meta-analyses
  - Level B – data derived from single randomized trial or nonrandomized studies
  - Level C – only consensus opinions of experts, case studies, or standard of care
- References
  - American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) 2006 guidelines on management of patients with atrial fibrillation (Circulation 2006 Aug 15;114(7):e257 full-text)
  - ACC/AHA/Heart Rhythm Society (HRS) 2011 focused update on management of patients with atrial fibrillation (Circulation 2011 Jan 4;123(1):104 PDF)
  - HRS/European Heart Rhythm Association (EHRA)/European Cardiac Arrhythmia Society (ECAS) 2012 expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design (Europace 2012 Apr;14(4):528 full-text or in Heart Rhythm 2012 Apr;9(4):632)

European Society of Cardiology (ESC) grading system for recommendations
- classes of recommendations
  - Class I – evidence and/or general agreement that given treatment or procedure is beneficial, useful, and effective
  - Class II – conflicting evidence and/or divergence of opinion about usefulness/efficacy of given treatment or procedure
    - Class IIa – weight of evidence/opinion in favor of usefulness/efficacy
    - Class IIb – usefulness/efficacy less well-established by evidence/opinion
  - Class III – evidence or general agreement that given treatment or procedure is not useful/effective, and in some cases may be harmful
- levels of evidence
  - Level A – data derived from multiple randomized clinical trials or meta-analyses
  - Level B – data derived from single randomized trial or large nonrandomized studies
  - Level C – consensus of opinion of experts and/or small studies, retrospective studies, registries
- References
  - ESC guideline on diagnosis and management of acute pulmonary embolism (Eur Heart J 2014 Nov 14;35(43):3033 full-text)
  - ESC focused update of guideline on management of atrial fibrillation (Eur Heart J 2012 Nov;33(21):2719 full-text)
  - ESC guideline on management of atrial fibrillation (Eur Heart J 2010 Oct;31(19):2369 full-text)
  - American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) guidelines on management of patients with supraventricular arrhythmias (J Am Coll Cardiol 2003 Oct 15;42(8):1493 full-text)

Canadian Cardiovascular Society (CCS) grading system for recommendations
- strength of recommendation
  - Strong
  - Conditional (weak)
- quality of evidence
  - High – future research unlikely to change confidence in estimate of effect; multiple well-designed, well-conducted clinical trials
  - Moderate – further research likely to have important impact on confidence in estimate of effect and may change estimate; limited clinical trials, inconsistency of results or study limitations
  - Low – further research very likely to have significant impact on estimate of effect and is likely to change estimate; small number of clinical studies or cohort observations
  - Very Low – estimate of effect is very uncertain; case studies
- Reference – Canadian Cardiovascular Society atrial fibrillation guidelines 2010: rate and rhythm management (Can J Cardiol 2011 Jan-Feb;27(1):47)

American College of Chest Physicians (ACCP) grades
- Grade 1 – strong recommendation based on clear risk/benefit balance
- Grade 2 – weak recommendation based on unclear or close risk/benefit balance
- Grade A – high-quality evidence based on consistent evidence from randomized trials without important limitations or exceptionally strong evidence from observational studies
- Grade B – moderate-quality evidence based on randomized trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise results) or very strong evidence from observational studies
- Grade C – low- or very low-quality evidence based on observational studies, case series, or randomized trials with serious flaws or indirect evidence
- Reference – ACCP Evidence-Based Clinical Practice Guidelines (9th ed.) Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines (Chest 2012 Feb;141(2 Suppl):53S full-text), commentary can be found in Chest 2013 Apr;143(4):1190