Elsevier

Heart Rhythm

Volume 4, Issue 6, June 2007, Pages 816-861
Heart Rhythm

News from the heart rhythm society
HRS/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

https://doi.org/10.1016/j.hrthm.2007.04.005Get rights and content

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

First page preview

First page preview
Click to open first page preview

References (353)

  • S. Stewart et al.

    A population-based study of the long-term risks associated with atrial fibrillation: 20–year follow-up of the Renfrew/Paisley study

    Am J Med

    (2002)
  • D.M. Clark et al.

    Hemodynamic effects of an irregular sequence of ventricular cycle lengths during atrial fibrillation

    J Am Coll Cardiol

    (1997)
  • S.H. Hohnloser et al.

    Rhythm or rate control in atrial fibrillation–Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial

    Lancet

    (2000)
  • J. Carlsson et al.

    Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study

    J Am Coll Cardiol

    (2003)
  • S.N. Singh et al.

    Quality of life and exercise performance in patients in sinus rhythm versus persistent atrial fibrillation: a Veterans Affairs Cooperative Studies Program Substudy

    J Am Coll Cardiol

    (2006)
  • C. Pappone et al.

    A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF Study

    J Am Coll Cardiol

    (2006)
  • H. Kottkamp et al.

    Time courses and quantitative analysis of atrial fibrillation episode number and duration after circular plus linear left atrial lesions: trigger elimination or substrate modification: early or delayed cure?

    J Am Coll Cardiol

    (2004)
  • G. Senatore et al.

    Role of transtelephonic electrocardiographic monitoring in detecting short-term arrhythmia recurrences after radiofrequency ablation in patients with atrial fibrillation

    J Am Coll Cardiol

    (2005)
  • T.M. Sundt et al.

    The maze procedure for cure of atrial fibrillation

    Cardiol Clin

    (1997)
  • T. Sueda et al.

    Efficacy of pulmonary vein isolation for the elimination of chronic atrial fibrillation in cardiac valvular surgery

    Ann.Thorac Surg

    (2001)
  • T. Yamada et al.

    Electrophysiological pulmonary vein antrum isolation with a multielectrode basket catheter is feasible and effective for curing paroxysmal atrial fibrillation: efficacy of minimally extensive pulmonary vein isolation

    Heart Rhythm

    (2006)
  • S. Ernst et al.

    Catheter-induced linear lesions in the left atrium in patients with atrial fibrillation: an electroanatomic study

    J Am Coll Cardiol

    (2003)
  • J. Jalife et al.

    Mother rotors and fibrillatory conduction: a mechanism of atrial fibrillation

    Cardiovasc Res

    (2002)
  • A. Shiroshita-Takeshita et al.

    Atrial fibrillation: basic mechanisms, remodeling and triggers

    J Interv Card Electrophysiol

    (2005)
  • Y.J. Chen et al.

    Electrophysiology of pulmonary veins

    J Cardiovasc Electrophysiol

    (2006)
  • M. Allessie et al.

    Electrical, contractile and structural remodeling during atrial fibrillation

    Cardiovasc Res

    (2002)
  • D. Dobrev et al.

    The G protein-gated potassium current I(K,ACh) is constitutively active in patients with chronic atrial fibrillation

    Circulation

    (2005)
  • T.H. Everett et al.

    Structural atrial remodeling alters the substrate and spatiotemporal organization of atrial fibrillation: a comparison in canine models of structural and electrical atrial remodeling

    Am J Physiol Heart Circ Physiol

    (2006)
  • S. Nattel

    New ideas about atrial fibrillation 50 years on

    Nature

    (2002)
  • M. Haissaguerre et al.

    Radiofrequency catheter ablation in unusual mechanisms of atrial fibrillation: report of three cases

    J Cardiovasc Electrophysiol

    (1994)
  • P. Jais et al.

    A focal source of atrial fibrillation treated by discrete radiofrequency ablation

    Circulation

    (1997)
  • M. Haissaguerre et al.

    Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins

    N Engl J Med

    (1998)
  • O. Berenfeld et al.

    Spatially distributed dominant excitation frequencies reveal hidden organization in atrial fibrillation in the Langendorff-perfused sheep heart

    J Cardiovasc Electrophysiol

    (2000)
  • R. Mandapati et al.

    Stable microreentrant sources as a mechanism of atrial fibrillation in the isolated sheep heart

    Circulation

    (2000)
  • A.C. Skanes et al.

    Spatiotemporal periodicity during atrial fibrillation in the isolated sheep heart

    Circulation

    (1998)
  • M.A. Allessie

    Experimental evaluation of moe’s multiple wavelet hypothesis of atrial fibrillation

  • D. Scherf

    Studies on auricular tachycardia caused by aconitine administration

    Proc Soc Exp Biol Med

    (1947)
  • M. Haissaguerre et al.

    Right and left atrial radiofrequency catheter therapy of paroxysmal atrial fibrillation

    J Cardiovasc Electrophysiol

    (1996)
  • H. Nathan et al.

    The junction between the left atrium and the pulmonary veinsAn anatomic study of human hearts

    Circulation

    (1966)
  • S.Y. Ho et al.

    Anatomy of the left atrium: implications for radiofrequency ablation of atrial fibrillation

    J Cardiovasc Electrophysiol

    (1999)
  • C. Weiss et al.

    Impact of the distribution and structure of myocardium in the pulmonary veins for radiofrequency ablation of atrial fibrillation

    Pacing Clin Electrophysiol

    (2002)
  • A.C. Gittenberger-de Groot et al.

    The role of neural crest and epicardium-derived cells in conduction system formation

    Novartis Found Symp

    (2003)
  • M.R. Jongbloed et al.

    Embryonic conduction tissue: a spatial correlation with adult arrhythmogenic areas

    J Cardiovasc Electrophysiol

    (2004)
  • A. Perez-Lugones et al.

    Evidence of specialized conduction cells in human pulmonary veins of patients with atrial fibrillation

    J Cardiovasc Electrophysiol

    (2003)
  • R. Weerasooriya et al.

    Dissociated pulmonary vein arrhythmia: incidence and characteristics

    J Cardiovasc Electrophysiol

    (2003)
  • D. Chung

    Electrical activity of the pulmonary vein and its interaction with the right atrium in the guinea pig

    J Physiol

    (2006)
  • W. Wongcharoen et al.

    Effects of a Na+/Ca2+ exchanger inhibitor on pulmonary vein electrical activity and ouabain-induced arrhythmogenicity

    Cardiovasc Res

    (2006)
  • R. Arora et al.

    Arrhythmogenic substrate of the pulmonary veins assessed by high-resolution optical mapping

    Circulation

    (2003)
  • M. Hocini et al.

    Electrical conduction in canine pulmonary veins: electrophysiological and anatomic correlation

    Circulation

    (2002)
  • J. Kalifa et al.

    Intra-atrial pressure increases rate and organization of waves emanating from the superior pulmonary veins during atrial fibrillation

    Circulation

    (2003)
  • Cited by (1115)

    View all citing articles on Scopus
    View full text