News from the heart rhythm societyHRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-Up: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and Approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society
Section snippets
Task Force Members
Chairs:
Hugh Calkins, MD, FHRS, Chair, Johns Hopkins Hospital, Maryland, USA
Josep Brugada, MD, FESC, Co-Chair, EHRA representative, Hospital Clinic, University of Barcelona, SPAIN
Section Chairs:
Atrial Fibrillation: Definitions, Mechanisms, and Rationale for Ablation—Shih-Ann Chen, MD, FHRS, Taipei Veterans General Hospital, TAIWAN
Indications for Ablation and Patient Selection—Eric N. Prystowsky, MD, FHRS, The Care Group, LLC, Indiana, USA
Techniques and Endpoints for Atrial Fibrillation—Karl
Table of Contents
I. Introduction......818
II. Atrial Fibrillation: Definitions, Mechanisms, and Rationale for Ablation......818
Definitions......818
Mechanisms of Atrial Fibrillation......819
Electrophysiologic Basis for Catheter Ablation of Atrial Fibrillation......822
Rationale for Eliminating Atrial Fibrillation with Ablation......823
III. Indications for Catheter Ablation of Atrial Fibrillation and Patient Selection......823
Patient Selection for Catheter Ablation of Atrial Fibrillation......824
IV. Techniques and
I. Introduction
During the past decade, catheter ablation of atrial fibrillation (AF) has evolved rapidly from a highly experimental unproven procedure, to its current status as a commonly performed ablation procedure in many major hospitals throughout the world. Surgical ablation of AF, using either standard or minimally invasive techniques, is also performed in many major hospitals throughout the world.
The purpose of this Consensus Statement is to provide a state-of-the-art review of the field of catheter
Definitions
AF is a common supraventricular arrhythmia that is characterized by chaotic and uncoordinated contraction of the atrium. The common electrocardiographic (ECG) manifestations of AF include the presence of irregular fibrillatory waves and, in patients with intact atrioventricular conduction, the presence of an irregular ventricular response. Although there are several classification systems for AF, for this consensus document we have adopted the classification system that was developed by the
III. Indications for Catheter Ablation of Atrial Fibrillation and Patient Selection
The ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation, written in collaboration with the Heart Rhythm Society, state that “Catheter ablation is a reasonable alternative to pharmacological therapy to prevent recurrent AF in symptomatic patients with little or no LA enlargement” (Class 2A recommendation, level of evidence C).1 It is noteworthy that the only Class 1 indication in this section of the document states that treatment of precipitating or reversible
Historical Considerations
Cox and colleagues are credited with developing and demonstrating the efficacy of surgical ablation of AF.18, 76 Subsequent surgeons evaluated the efficacy of surgical approaches that limit the lesion set to PV isolation.77, 78 The final iteration of the procedure developed by Cox, which is referred to as the Maze-III procedure, was based on a model of AF in which maintenance of the arrhythmia was shown to require maintenance of a critical number of circulating wavelets of reentry. The success
Energy Sources—Radiofrequency Energy
The presumed basis of successful AF ablation is production of myocardial lesions that block the propagation of AF wave fronts from a rapidly firing triggering source, or modification of the arrhythmogenic substrate responsible for reentry. Successful ablation depends upon achieving lesions that are reliably transmural.120, 121 The conventional approach employed by cardiac electrophysiologists to reach the goal of AF ablation is RF energy delivery by way of a transvenous electrode catheter.
RF
Anticoagulation and Strategies to Prevent Thromboembolism
Careful attention to anticoagulation of patients before, during, and after ablation for AF is critical to avoid the occurrence of a thromboembolic event, which is recognized as one of the most serious complications of AF and also of AF ablation procedures. Anticoagulation, in turn, contributes to some of the most common complications of the procedure, including hemopericardium/pericardial tamponade and vascular complications.178 Therefore, attention must be paid to achieving the optimal safe
ECG Monitoring Pre and Post Procedure
Arrhythmia monitoring is an important component of the initial evaluation of patients who are to undergo catheter ablation procedures for AF. Prior to undergoing a catheter ablation procedure, it is important to confirm that a patient’s symptoms result from AF and to determine whether a patient has paroxysmal or persistent AF. This is of importance as the ablation technique, procedure outcome, anticoagulation strategies employed, and the need for TEE prior to the procedure may be impacted by
Overview
The efficacy of any type of ablation procedure can be determined from a variety of sources including: (1) single center randomized or nonrandomized clinical trials, (2) multicenter randomized or nonrandomized clinical trials, and (3) physician surveys. Among these sources of outcome data, it is well recognized that data derived from large prospective randomized clinical trials most accurately reflect the outcomes that can be anticipated when a procedure is performed in clinical practice.
IX. Complications of Atrial Fibrillation Ablation
Catheter ablation of AF is one of the most complex interventional electrophysiologic procedures. It is therefore to be expected that the risk associated with AF ablation is higher than for ablation of most other cardiac arrhythmias. This section reviews the complications associated with AF ablation procedures. Particular attention is focused on the most frequently occurring complications and those likely to result in prolonged hospitalization, long-term disability, or death. We recognize that
X. Training Requirements and Competencies
The strategies, specific methods, and technology pertaining to ablation of AF are evolving. Accordingly, the guidelines for training to perform this procedure must be flexible in recognition of different approaches and technologies that will change with advances in the field. Training for ablation of AF should encompass six fundamental principles:
- 1
Appropriate selection of patients
- 2
Knowledge of anatomy of the atria and adjacent structures
- 3
Conceptual knowledge of strategies to ablate AF
- 4
Technical
Development of the Cox-Maze Procedure
Following extensive experimental investigation, the Maze procedure was introduced for the surgical treatment of AF in 1987 by Dr. James Cox.18, 293, 294 This procedure was designed to interrupt all macro-reentrant circuits that might potentially develop in the atria, thereby precluding the ability of the atrium to flutter or fibrillate. Fortuitously, the operation also isolated all of the PVs and posterior LA. In contrast to previous unsuccessful procedures, the Cox-Maze procedure successfully
Overview
It is clear that tremendous progress has been made in the development of non-pharmacologic therapies for the treatment of patients with AF. Most of what has been learned about catheter and surgical AF ablation has been derived from single center clinical studies. In most cases, these studies reflect the experience of large academic centers, the outcomes of which may or may not be replicated by smaller centers. It is also clear that the inherent design of such cumulative studies leave many
XIII. Conclusion
Catheter and surgical ablation of AF are commonly performed procedures throughout the world. This document provides an up-to-date review of the indications, techniques, and outcomes of catheter and surgical ablation of AF. Areas for which a consensus can be reached concerning AF ablation are identified. It is important to note that this statement summarizes the opinion of the Task Force members based on their experience and a review of the literature. It is also important to note that when we
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