What are the guidelines for catheter ablation for atrial fibrillation (Afib) (AF)?

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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Both the 2014 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) and 2012 European Society of Cardiology updated guidelines suggest a more prominent role for radiofrequency ablation in the treatment of atrial fibrillation (AF), including its use as first-line therapy in recurrent symptomatic paroxysmal or persistent AF. [1, 149]

According to AHA/ACC/HRS guidelines, AF catheter ablation is contraindicated for patients who cannot be treated with anticoagulant therapy during and after the procedure and should not be performed with the sole intent of eliminating the need for anticoagulation. [1]

The 2017 HRS/EHRA/ECAS/APHRS/SOLAECE (HRS, European Heart Rhythm Association, European Cardiac Arrhythmia Society, Asia Pacific Heart Rhythm Society, and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología [SOLAECE]) expert consensus statement on catheter and surgical ablation of AF completely supersedes the 2012 HRS/EHRA/ECAS expert consensus statement. It provides updated definitions, mechanisms, and rationale for AF ablation and consensus recommendations concerning indications, strategies, techniques, and endpoints, technology and tools, and follow-up considerations for AF ablation.

Key points of this document include the following [154] :

  • Catheter and surgical ablation of AF are well established and important treatment options for patients with AF in whom a rhythm control strategy is chosen.
  • Careful consideration of the efficacy, risks, and alternatives to the ablation procedure as well as patient preferences should inform decision making about selection of catheter or surgical ablation of AF. Indications for both catheter and surgical AF ablation are presented.
  • The key indication for AF ablation is the presence of symptoms associated with AF, typically after ineffectiveness or intolerance of at least one antiarrhythmic medication.
  • A desire to stop anticoagulation is not an appropriate indication for AF ablation. For most patients with AF at high risk for stroke, anticoagulation should be continued following the ablation procedure.
  • Catheter ablation of AF is associated with a risk of complications, such as the development of a stroke or transient ischemic attack. Closely monitor anticoagulation before, during, and after the ablation procedure to minimize these risks.
  • Multiple tools and strategies are available to perform both catheter and surgical ablation of AF. The consensus statement provides a detailed review of each of the available options, as well as recommendations.

The 2019 ACC/AHA/HRS focused update on the management of patients with AF indicates that AF catheter ablation may be reasonable in selected patients with symptomatic AF and heart failure (HF) with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower the mortality rate and reduce hospitalization for HF. [57]

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