Catheter and Surgical Ablation of Atrial Fibrillation
Publication Date: April 8, 2024
Last Updated: December 16, 2022
Diagnosis
Table 2a. Indications for Catheter Ablation of Atrial Fibrillation
Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication
Paroxysmal: Catheter ablation is recommended. (I, A)
573
Persistent: Catheter ablation is reasonable. (IIa, B-NR)
573
Long-standing persistent: Catheter ablation may be considered. (IIb, C-LD)
573
Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class 1 or 3 antiarrhythmic medication
Paroxysmal: Catheter ablation is reasonable. (IIa, B-R)
573
Persistent: Catheter ablation is reasonable. (IIa, C-EO)
573
Long-standing persistent: Catheter ablation may be considered. (IIb, C-EO)
573
Table 2b. Indications for Atrial Fibrillation Ablation in Populations of Patients Not Well Represented in Clinical Trials
Congestive heart failure
It is reasonable to use similar indications for AF ablation in selected patients with heart failure as in patients without heart failure. (IIa, B-R)
573
Older patients (>75 years of age)
It is reasonable to use similar indications for AF ablation in selected older patients with AF as in younger patients. (IIa, B-NR)
573
Hypertrophic cardiomyopathy
It is reasonable to use similar indications for AF ablation in selected patients with HCM as in patients without HCM. (IIa, B-NR)
573
Young patients (<45 years of age)
It is reasonable to use similar indications for AF ablation in young patients with AF (<45 years of age) as in older patients. (IIa, B-NR)
573
Tachy-brady syndrome
It is reasonable to offer AF ablation as an alternative to pacemaker implantation in patients with tachy-brady syndrome. (IIa, B-NR)
573
Athletes with AF
It is reasonable to offer high-level athletes AF ablation as first-line therapy due to the negative effects of medications on athletic performance. (IIa, C-LD)
573
Asymptomatic AFa
Paroxysmal: Catheter ablation may be considered in select patients.a (IIb, C-EO)
573
Persistent: Catheter ablation may be considered in select patients. (IIb, C-EO)
573
a A decision to perform AF ablation in an asymptomatic patient requires additional discussion with the patient as the potential benefits of the procedure for the patient without symptoms are uncertain.
Table 2c. Indications for Concomitant Open (such as Mitral Valve) Surgical Ablation of Atrial Fibrillation
Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication
Paroxysmal: Surgical ablation is recommended. (I, B-NR)
573
Persistent: Surgical ablation is recommended. (I, B-NR)
573
Long-standing persistent: Surgical ablation is recommended. (I, B-NR)
573
Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class 1 or 3 antiarrhythmic medication
Paroxysmal: Surgical ablation is recommended. (I, B-NR)
573
Persistent: Surgical ablation is recommended. (I, B-NR)
573
Long-standing persistent: Surgical ablation is recommended. (I, B-NR)
573
Table 2d. Indications for Concomitant Closed (such as CABG and AVR) Surgical Ablation of Atrial Fibrillation
Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication
Paroxysmal: Surgical ablation is recommended. (I, B-NR)
573
Persistent: Surgical ablation is recommended. (I, B-NR)
573
Long-standing persistent: Surgical ablation is recommended. (I, B-NR)
573
Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class 1 or 3 antiarrhythmic medication
Paroxysmal: Surgical ablation is reasonable. (IIa, B-NR)
573
Persistent: Surgical ablation is reasonable. (IIa, B-NR)
573
Long-standing persistent: Surgical ablation is reasonable. (IIa, B-NR)
573
Table 2e. Indications for Stand-Alone and Hybrid Surgical Ablation of Atrial Fibrillation
Symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication
Paroxysmal: Stand-alone surgical ablation can be considered for patients who have failed one or more attempts at catheter ablation and also for those who are intolerant or refractory to antiarrhythmic drug therapy and prefer a surgical approach, after review of the relative safety and efficacy of catheter ablation versus a stand-alone surgical approach. (IIb, B-NR)
573
Persistent: Stand-alone surgical ablation is reasonable for patients who have failed one or more attempts at catheter ablation and also for those patients who prefer a surgical approach after review of the relative safety and efficacy of catheter ablation versus a stand-alone surgical approach. (IIa, B-NR)
573
Long-standing persistent: Stand-alone surgical ablation is reasonable for patients who have failed one or more attempts at catheter ablation and also for those patients who prefer a surgical approach after review of the relative safety and efficacy of catheter ablation versus a stand-alone surgical approach. (IIa, B-NR)
573
It may be reasonable to apply the indications for stand-alone surgical ablation described above to patients being considered for hybrid surgical AF ablation. (IIb, C-EO)
573
Treatment
Table 3. Atrial Fibrillation Ablation: Strategies, Techniques, and Endpoints
PV isolation by catheter ablation
Electrical isolation of the PVs is recommended during all AF ablation procedures. (I, A)
573
Achievement of electrical isolation requires, at a minimum, assessment and demonstration of entrance block into the PV. (I, B-R)
573
Monitoring for PV reconnection for 20 minutes following initial PV isolation is reasonable. (IIa, B-R)
573
Administration of adenosine 20 minutes following initial PV isolation using RF energy with reablation if PV reconnection may be considered. (IIb, B-R)
573
Use of a pace-capture (pacing along the ablation line) ablation strategy may be considered. (IIb, B-R)
573
Demonstration of exit block may be considered. (IIb, B-NR)
573
Ablation strategies to be considered for use in conjunction with PV isolation
If the patient has a history of typical atrial flutter or typical atrial flutter is induced at the time of AF ablation, delivery of a cavotricuspid isthmus linear lesion is recommended. (I, B-R)
573
If linear ablation lesions are applied, operators should use mapping and pacing maneuvers to assess for line completeness. (I, C-LD)
573
If a reproducible focal trigger that initiates AF is identified outside the PV ostia at the time of an AF ablation procedure, ablation of the focal trigger should be considered. (IIa, C-LD)
573
When performing AF ablation with a force-sensing RF ablation catheter, a minimal targeted contact force of 5–10 grams is reasonable. (IIa, C-LD)
573
Ablation strategies to be considered for use in conjunction with PV isolation
Posterior wall isolation might be considered for initial or repeat ablation of persistent or long-standing persistent AF. (IIb, C-LD)
573
Administration of high-dose isoproterenol to screen for and then ablate non-PV triggers may be considered during initial or repeat AF ablation procedures in patients with paroxysmal, persistent, or long-standing persistent AF. (IIb, C-LD)
573
Dominant excitation frequency (DF)-based ablation strategy is of unknown usefulness for AF ablation. (IIb, C-LD)
573
The usefulness of creating linear ablation lesions in the right or left atrium as an initial or repeat ablation strategy for persistent or long-standing persistent AF is not well established. (IIb, B-NR)
573
The usefulness of linear ablation lesions in the absence of macroreentrant atrial flutter is not well established. (IIb, C-LD)
573
The usefulness of mapping and ablation of areas of abnormal myocardial tissue identified with voltage mapping or MR imaging as an initial or repeat ablation strategy for persistent or long standing persistent AF is not well established. (IIb, B-R)
573
The usefulness of ablation of complex fractionated atrial electrograms as an initial or repeat ablation strategy for persistent and long- standing persistent AF is not well established. (IIb, B-R)
573
The usefulness of ablation of rotational activity as an initial or repeat ablation strategy for persistent and long-standing persistent AF is not well established. (IIb, B-NR)
573
The usefulness of ablation of autonomic ganglia as an initial or repeat ablation strategy for paroxysmal, persistent, and long-standing persistent AF is not well established. (IIb, B-NR)
573
Nonablation strategies to improve outcomes
Weight loss can be useful for patients with AF, including those who are being evaluated to undergo an AF ablation procedure, as part of a comprehensive risk factor management strategy. (IIa, B-R)
573
It is reasonable to consider a patient’s body mass index (BMI) when discussing the risks, benefits, and outcomes of AF ablation with a patient being evaluated for an AF ablation procedure. (IIa, B-R)
573
It is reasonable to screen for signs and symptoms of sleep apnea when evaluating a patient for an AF ablation procedure and recommend a sleep evaluation if sleep apnea is suspected. (IIa, B-R)
573
Treatment of sleep apnea can be useful for patients with AF, including those who are being evaluated to undergo an AF ablation procedure. (IIa, B-R)
573
The usefulness of discontinuation of antiarrhythmic drug therapy prior to AF ablation in an effort to improve long-term outcomes is unclear. (IIb, C-LD)
573
The usefulness of initiation or continuation of antiarrhythmic drug therapy during the post ablation healing phase in an effort to improve long-term outcomes is unclear. (IIb, C-LD)
573
Strategies to reduce the risks of AF ablation
Careful identification of the PV ostia is mandatory to avoid ablation within the PVs. (I, B-NR)
573
It is recommended that RF power be reduced when creating lesions along the posterior wall near the esophagus. (I, C-LD)
573
It is reasonable to use an esophageal temperature probe during AF ablation procedures to monitor esophageal temperature and help guide energy delivery. (IIa, C-EO)
573
Table 4. Anticoagulation Strategies: Pre-, During, and Post-Catheter Ablation of AF
Preablation
For patients undergoing AF catheter ablation who have been therapeutically anticoagulated with warfarin or dabigatran, performance of the ablation procedure without interruption of warfarin or dabigatran is recommended. (I, A)
573
For patients undergoing AF catheter ablation who have been therapeutically anticoagulated with rivaroxaban, performance of the ablation procedure without interruption of rivaroxaban is recommended. (I, B-R)
573
For patients undergoing AF catheter ablation who have been therapeutically anticoagulated with a NOAC other than dabigatran or rivaroxaban, performance of the ablation procedure without withholding a NOAC dose is reasonable. (IIa, B-NR)
573
Anticoagulation guidelines that pertain to cardioversion of AF should be adhered to in patients who present for an AF catheter ablation procedure. (I, B-NR)
573
For patients anticoagulated with a NOAC prior to AF catheter ablation, it is reasonable to hold one to two doses of the NOAC prior to AF ablation with reinitiation postablation. (IIa, B-NR)
573
Performance of a transesophageal echocardiogram (TEE) in patients who are in AF on presentation for AF catheter ablation and have been anticoagulated therapeutically for 3 weeks or longer is reasonable. (IIa, C-EO)
573
Performance of a TEE in patients who present for ablation in sinus rhythm and who have not been anticoagulated prior to catheter ablation is reasonable. (IIa, C-EO)
573
Use of intracardiac echocardiography to screen for atrial thrombi in patients who cannot undergo TEE may be considered. (IIb, C-EO)
573
During ablation
Heparin should be administered prior to or immediately following transeptal puncture during AF catheter ablation procedures and adjusted to achieve and maintain an activated clotting time (ACT) of at least 300 seconds. (I, B-NR)
573
Administration of protamine following AF catheter ablation to reverse heparin is reasonable. (IIa, B-NR)
573
Postablation
In patients who are not therapeutically anticoagulated prior to catheter ablation of AF and in whom warfarin will be used for anticoagulation postablation, low molecular weight heparin or intravenous heparin should be used as a bridge for initiation of systemic anticoagulation with warfarin following AF ablation. (I, C-EO)
573
Systemic anticoagulation with warfarin or a NOAC is recommended for at least 2 months postcatheter ablation of AF. (I, C-EO)
573
Adherence to AF anticoagulation guidelines is recommended for patients who have undergone an AF ablation procedure, regardless of the apparent success or failure of the procedure. (I, C-EO)
573
Decisions regarding continuation of systemic anticoagulation more than 2 months postablation should be based on the patient’s stroke risk profile and not on the perceived success or failure of the ablation procedure. (I, C-EO)
573
In patients who have not been anticoagulated prior to catheter ablation of AF or in whom anticoagulation with a NOAC or warfarin has been interrupted prior to ablation, administration of a NOAC 3 to 5 hours after achievement of hemostasis is reasonable postablation. (IIa, C-EO)
573
Patients in whom discontinuation of anticoagulation is being considered based on patients values and preferences should consider undergoing continuous or frequent ECG monitoring to screen for AF recurrence. (IIb, C-EO)
573
Recommendation Grading
Overview
Title
Catheter and Surgical Ablation of Atrial Fibrillation
Authoring Organization
Heart Rhythm Society
Publication Month/Year
April 8, 2024
Last Updated Month/Year
November 21, 2024
Document Type
Consensus
External Publication Status
Published
Country of Publication
Global
Document Objectives
The objective of this consensus document is to provide practical guidance and set standards in the selection and management (preprocedural, procedural, and postprocedural) of patients considered for or undergoing atrial fibrillation (AF) ablation. Specific sections are devoted to AF pathophysiology, anatomical considerations, evaluation and management of complications, training, and institutional requirements for AF ablation.
Target Patient Population
Patients considered for or undergoing atrial fibrillation (AF) ablation
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Hospital, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Treatment
Diseases/Conditions (MeSH)
D001281 - Atrial Fibrillation, D020517 - Atrial Appendage, D001282 - Atrial Flutter, D013612 - Tachycardia, Ectopic Atrial
Keywords
atrial fibrillation, anticoagulation, catheter ablation, stroke, atrial tachycardia (AT), atrial flutter, ablation, arrhythmia, surgical ablation, Anticoagulation
Source Citation
Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY, Steven D, Agbayani MJ, Jared Bunch T, Chugh A, Díaz JC, Freeman JV, Hardy CA, Heidbuchel H, Johar S, Linz D, Maesen B, Noseworthy PA, Oh S, Porta-Sanchez A, Potpara T, Rodriguez-Diez G, Sacher F, Suwalski P, Trines SA. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2024 Mar 30;26(4):euae043. doi: 10.1093/europace/euae043. PMID: 38587017; PMCID: PMC11000153.