Core Concepts
The updated expert consensus statement provides practical advice to optimize the selection and management of patients undergoing catheter or surgical ablation for atrial fibrillation, incorporating recent advancements in techniques and technologies.
Abstract
The updated expert consensus statement on catheter and surgical ablation of atrial fibrillation (AF) was developed through a collaboration of four cardiac electrophysiology societies: the European Heart Rhythm Association (EHRA), Heart Rhythm Society, Asia Pacific Heart Rhythm Society, and Latin American Heart Rhythm Society.
Key highlights:
Indications:
Catheter ablation is now recommended as a first-line treatment for patients with symptomatic paroxysmal AF, based on evidence of superior efficacy and similar safety compared to antiarrhythmic drugs.
Catheter ablation can be considered in selected patients with AF and heart failure with systolic dysfunction, if AF is suspected to be the cause of the systolic dysfunction.
Pre-Procedure Management:
Exclusion of left atrial thrombus is crucial, and the consensus statement advises the use of intracardiac echocardiography, cardiac CT, or transesophageal echocardiography for this purpose.
Ablation Strategies:
Pulmonary vein isolation (PVI) remains the cornerstone of AF ablation, with no major progress in additional ablation strategies beyond PVI for persistent AF.
The consensus discourages the use of MRI-guided ablation strategies due to increased complications.
Procedural Management:
Strong recommendation for the use of ultrasound-guided vascular access to reduce the risk of vascular complications.
Downgrading of the role of esophageal temperature monitoring, as it does not seem to provide substantial benefit in preventing esophageal lesions.
Post-Procedure Management:
Anticoagulation is recommended for all patients in the early post-ablation period (first 2 months).
For the late post-ablation period, anticoagulation recommendations are based on thromboembolic risk stratification.
Antiarrhythmic drugs are only recommended to prevent early AF recurrences, not for long-term prevention.
Future Aims:
Shortening the blanking period (initial period after ablation where recurrences are not considered treatment failures) from 3 months to 8 weeks.
Reporting AF burden as an important outcome, in addition to the traditional binary success/failure definition.
Developing and validating tools to identify the optimal candidates for AF ablation, especially in the setting of heart failure.
Stats
"Catheter ablation is a very important tool in our armamentarium against AF."
"For persistent AF there is a grey zone — we need more data. We don't have enough data to support use of catheter ablation for first-line treatment in this group."
"The presence of thrombus is a contraindication for catheter ablation. This is extremely important because thrombus is the main reason for many of the most frequent complications of AF — thromboembolic events such as stroke."
"We now have strong data to show that this approach [ultrasound-guided vascular access] significantly reduces the risk of vascular complications, which remain the most frequent adverse effect of catheter ablation."
"We strongly suggest that upcoming clinical trials should be designed with a blanking period of 8 weeks."
Quotes
"In a clinical setting, it is the quantification of the arrhythmia that is important. We strongly suggest AF burden before and after ablation is reported, and the difference is used as a relevant outcome."
"There is a huge difference between arrhythmia durations of 30 seconds and 1 hour, and at the end of the day, we must not forget that the aim of this treatment is to alleviate patients' symptoms. Someone may have a recurrence of 1 minute and that may be symptomatic, so needs to be considered as important."