HEART RHYTHM SOCIETY

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Ablation of Atrial Fibrillation
Summary from the HRS/EHRA/ECAS Expert Consensus
Statement on Catheter and Surgical Ablation of
Atrial Fibrillation Calkins H et al. Heart Rhythm
2007 4(6) 816-61
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Atrial Fibrillation AblationPatient Selection,
Contraindications and Management
K.L.Venkatachalam MD Mayo Clinic Jacksonville, FL
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Atrial Fibrillation Ablation

• Who should be offered atrial fibrillation
  ablation?
• Primary selection criteria are patients with
  symptomatic atrial fibrillation, refractory
  or intolerant to at least one Class 1 or
  Class 3 anti-arrhythmic drug.
• Confirm that symptoms are due to atrial
  fibrillation and not due to co-morbidities.
• A desire to stop anti-coagulation is not an
  appropriate indication for AF ablation

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Atrial Fibrillation Ablation

• Who should be offered atrial fibrillation
  ablation?
• The best results for AF ablation are seen in
  patients with paroxysmal AF who are less than 70
  years of age, have a left atrial size less than 5
  cm, and do not have other significant
  co-morbities including severe obesity, sleep
  apnea, and heart failure.
• There are no absolute age or left atrial size cut
  offs that exclude a patient from consideration of
  AF ablation.
• AF ablation can also be offered to those with
  persistent and long standing persistent AF but
  the expected efficacy is less.

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Atrial Fibrillation Ablation

• Who should be offered atrial fibrillation
  ablation?
• May be considered first-line therapy in young,
  symptomatic patients and
• Selected symptomatic patients with heart failure
  or reduced EF.

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Atrial Fibrillation Ablation

• Which clinical factors are associated with lower
  efficacy of atrial fibrillation ablation?
• Long standing persistent AF
• Sleep apnea
• Increased left atrial size (gt 5.5 cm)
• Increased age (gt 70 yrs)

There are no cut off levels to exclude a patient
from consideration for AF ablation. But these
factors should be considered when speaking with a
patient about the risks and benefits of the
procedure.
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Atrial Fibrillation Ablation

• Peri-procedural Management
• Low molecular weight heparin or IV heparin
  should be used as a bridge to resumption of
  systemic anticoagulation for patients in
  whom warfarin was stopped prior to ablation or in
  whom warfarin is being started for the first
  time after ablation.
• Alternatively, ablation can be performed in
  patients on warfarin with a therapeutic INR.
  Patients undergoing ablation with a
  therapeutic INR should also receive heparin
  during the procedure.

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Atrial Fibrillation Ablation

• Peri-procedural Management
• Patients with persistent atrial fibrillation
  who are in atrial fibrillation at the time of
  ablation should have a transesophageal
  echocardiogram to screen for thrombus.
• Warfarin should be continued for at least 2
  months following ablation. Decisions to
  discontinue should be made on the basis of
  stroke risk factors.

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Atrial Fibrillation Ablation

• Peri-procedural Management
• Maintain ACT between 300 and 400 seconds
  during left-sided procedure with IV heparin.
• Ablation strategies should target the pulmonary
  veins and/or pulmonary vein antra with a goal
  of achieving electrical PV isolation.

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Atrial Fibrillation Ablation

• Peri-procedural Management
• If pulmonary veins are targeted, goal should
  be complete electrical isolation.
• During atrial fibrillation ablation, if a focal
  trigger outside the pulmonary vein is
  identified, it should be targeted, if
  possible.
• If linear lesions are applied, bi-directional
  block along the line should be confirmed.

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Atrial Fibrillation Ablation

• Peri-procedural Management
• Cavo-triscupid isthmus ablation is recommended
  only in patients with a history of typical
  atrial flutter or inducible cavo-tricuspid
  isthmus dependent atrial flutter
• In patients with longstanding persistent atrial
  fibrillation, ostial pulmonary vein isolation
  may need to be supplemented with linear
  lesions (LA roof line, mitral isthmus line),
  ganglionated plexus ablation or ablation in
  areas with complex fractionated atrial
  electrograms.

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Atrial Fibrillation Ablation

• Post-procedural Monitoring
• Patients should be seen in follow-up (with ECG)
  at a minimum of three months following
  ablation and then every six months for at
  least two years.
• Event monitoring should be used to screen for
  recurrent atrial fibrillation/atrial
  flutter/atrial tachycardia in patients with
  palpitations post-ablation.

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Atrial Fibrillation Ablation

• Repeat Procedures
• Repeat procedures should be delayed for at
  least three months following initial
  ablation, if symptoms can be controlled with
  medical therapy.