Mechanisms of Patient Selection

Patient Selection for AF Ablation Shown in the table are some of the many Estimated Outcomes and Risks of AF Ablation The estimates provided on this table

A B C D More Less variables which may impact patient selection Single Multiple are not based on the outcomes of large Optimal Patient Optimal Patient for of AF, either because Success Procedure Procedures prospective multicenter clinical trials. Variable they impact patient outcomes or they reflect Optimal patient 60% - 80% 80% - 90% These estimates are based on a review of Symptoms highly minimally symptomatic symptomatic the severity of the patient’s symptoms and Less optimal patient 50% - 70% 70% - 80% the published literature. It is recognized response to antiarrhythmic drug therapy. It is that the outcomes of AF ablation depend Class 1 and 3 drugs failed ≥ 1 0 Poor candidate < 40% 40% - 60% important to recognize that there are no ab- on a large number of variables including longstanding AF type paroxysmal solute cut-offs to determine which patients those shown in the table. In addition, the persistent Major complication rates: 2% - 12% are and are not candidates for AF ablation. technique and tools used may also impact Age younger (< 70 yrs) older ( ≥ 70 yrs) Left atrial flutter 2% - 5% Although this table has suggested certain outcomes. And finally, the experience of Vascular/access related 1% - 5% LA size smaller (< 5 cm) larger ( ≥ 5 cm) age and left atrial size cut-offs to determine the operator and of the ablation center at Cardiac tamponade 0.5% - 3% Structure and Shown in the Figure is a schematic drawing of the left and right atria as viewed from Ejection fraction normal reduced which patients are better candidates for AF which the procedure is performed also the posterior. The extension of muscular fibers onto the PVs can be appreciated. In Congestive 0.5% - 2% Mechanisms of no yes ablation, these are estimates and are not impact success and complication rates. heart failure Atrial Fibrillation yellow are the four major left atrial autonomic ganglionic plexi and axons (superior based on large prospective clinical trials. PV stenosis < 1% left, inferior left, anterior right, and inferior right). In blue is the coronary sinus which Other cardiac disease no yes The only absolute contraindications for AF Phrenic nerve injury < 0.5% is enveloped by muscular fibers which have connections to the atria. Also in blue is Pulmonary disease no yes ablation identified by the consensus writ- Adapted from Circulation, Esophageal perforation < 0.2% the vein and ligament of Marshall which travels from the coronary sinus to the region ing group were the presence of a left atrial Am J Cardiol, Tex Heart Inst J Sleep apnea no yes Mitral valve entrapment < 0.1% between the left superior PV and the left atrial appendage. thrombus or the inability of a patient to be Obesity no yes Acute coronary occlusion < 0.1% B: the large and small reentrant wavelets that play a role in initiating and systemically anticoagulated during and fol- Prior stroke/TIA no yes Death < 0.1% sustaining AF. lowing the ablation procedure. C: the common locations of PV (red) and also the common sites of origin of non PV triggers (shown in green). D: a composite of the anatomic and arrhythmic mechanisms of AF. Areas of Consensus

Indications for Surgical AF Ablation n If additional linear lesions are applied, line com- Follow-up and Clinical Trial Considerations A B C D Definitions, Indications, pleteness should be demonstrated by mapping or Abalation Techniques n Symptomatic AF patients undergoing other cardiac Blanking Period pacing maneuvers. surgery. n A blanking period of three months should be em- n Ablation of the cavotricuspid isthmus is recom- AF Definition n Selected asymptomatic AF patients undergoing ployed after ablation when reporting outcomes. cardiac surgery in whom the ablation can be performed mended only in patients with a history of typical n Paroxysmal AF is defined as recurrent AF(> 2 episodes) with minimal risk. atrial flutter or inducible cavotricuspid isthmus Definition of Success that terminates spontaneously within seven days. dependent atrial flutter. n Stand-alone AF surgery should be considered for n Freedom from AF/flutter/ off antiarrhyth- n Persistent AF is defined as AF which is sustained symptomatic AF patients who prefer a surgical approach, n If patients with long-standing persistent AF are mic therapy is the primary endpoint of AF ablation. beyond seven days, or lasting less than seven days but approached, ostial PV isolation alone may not be have failed one or more attempts at catheter ablation, or n For research purposes, time to recurrence of AF necessitating pharmacologic or electrical cardioversion. sufficient. Schematic of Figure shows the circumferential ablation lesions, which are created in a circumfer- are not candidates for catheter ablation. following ablation is an acceptable end point after AF n Longstanding persistent AF is defined as continuous ential fashion around the right and the left PVs. The primary endpoint of this ablation ablation, but may under represent true benefit. Common Lesion Pre-procedure Management strategy is the electrical isolation of the PV musculature. AF of greater than one-year duration. Post Procedure Management Sets Employed n Freedom from AF at various points following ablation n The term permanent AF is not appropriate in the con- n Patients with persistent AF who are in AF at the time B: some of the most common sites of linear ablation lesions. These include a “roof may be a better marker of true benefit and should be in AF Ablation text of patients undergoing catheter ablation of AF as it of ablation should have a TEE performed to screen for Anticoagulation Strategies line” connecting the lesions encircling the left and and/or right PVs, a “mitral considered as a secondary endpoint of ablation. thrombus. isthmus” line connecting the mitral valve and the lesion encircling the left PVs at the refers to a group of patients where a decision has been n Heparin should be administered during AF ablation n Adapted from Circulation, Am J made not to pursue restoration of sinus rhythm by any Atrial flutter and other atrial tachyarrhythmias level of the left inferior PV, and an anterior linear lesion connecting either the “roof Ablation Techniques procedures to achieve and maintain an ACT of 300 to Cardiol, Tex Heart Inst J. should be considered as treatment failures. line” or the left or right circumferential lesion to the mitral annulus anteriorly. Also means, including catheter or surgical ablation. 400 sec. n Ablation strategies which target the PVs and/or n An episode of AF/flutter/tachycardia detected by shown is a linear lesion created at the cavotricuspid isthmus. This lesion is generally Indications for Catheter AF Ablation n Low molecular weight Heparin or intravenous PV antrum are the cornerstone for most AF ablation monitoring should be considered a recurrence if it has placed in patients who have experienced cavotricuspid isthmus dependent atrial Heparin should be used as a bridge to resumption of n Symptomatic AF refractory or intolerant to at least procedures. a duration of 30 seconds or more. flutter clinically or have it induced during EP testing. systemic anticoagulation following AF ablation. one Class 1 or 3 antiarrhythmic medication. n If the PVs are targeted, complete electrical isolation n Single procedure success should be reported in all C: the addition of additional linear ablation lesions between the superior and inferior n Coumadin is recommended for all patients for at n In rare clinical situations, it may be appropriate to should be the goal. PVs resulting in a figure of 8 lesion set. Also shown is an encircling lesion of the trials of catheter ablation of AF. perform AF ablation as first line therapy. least two months following an AF ablation procedure. superior vena cava directed at electrical isolation of the superior vena cava. SVC n For surgical PV isolation, entrance and/or exit block n Decisions regarding the use of Coumadin more than Repeat Procedures isolation is performed if focal firing from the SVC can be demonstrated. A subset of n Selected symptomatic patients with heart failure should be demonstrated. two months following ablation should be based on the n Repeat procedures should be delayed for at least operators empirically isolate the SVC. and/or reduced ejection fraction. n Careful identification of the PV ostia is mandatory to patient’s risk factors for stroke and not on the pres- three months following initial ablation, if the patient’s n The presence of a left atrial thrombus is a contra- avoid ablation within the PVs. D: some of the most common sites of ablation lesions when complex fractionated ence or type of AF. symptoms can be controlled with medical therapy. electrograms are targeted. indication to catheter ablation of AF. n If a focal trigger is identified outside a PV at the time n Discontinuation of Warfarin therapy post ablation of an AF ablation procedure, it should be targeted if is generally not recommended in patients who have a possible. CHADs score ≥ 2.

Heart Rhythm Society Tel: (202) 464-3400 1400 K St NW, Suite 500 Fax: (202) 464-3401 SM Background Washington DC 20005 www.HRSonline.org SM Shown in the figure are some of the many During the past decade, catheter ablation of atrial fibrillationvariables (AF) which has mayevolved impact rapidly patient from selection for catheter ablation of AF, either because a highly experimental unproven procedure, to its current status as a commonly performed they impact patient outcomes or they reflect Pocket Guide ablation procedure in many major hospitals throughout thethe severity world. Surgical of the patient’s ablation symptoms of AF, and AF 3600 provides a single, trusted resource for the comprehensive and relevant information and response to antiarrhythmic drug therapy. It is using either standard or minimally invasive techniques, is also performed in many major education on Atrial Fibrillation (AF). AF 3600 is an initiative of the Heart Rhythm Society, the world’s important to recognize that there are no ab- hospitals throughout the world. solute cut-offs to determine which patients leading professional society for improving the care of cardiac patients by promoting sci- are and are not candidates for AF ablation. ence, education and optimal healthcare policies and standards. To learn more about AF 3600 or the In 2007, a Task Force convened by the Heart Rhythm Society,Although partnered this figure with hasthe suggestedEuropean certain age and left atrial size cut-offs to determine Heart Rhythm Society, visit www.HRSonline.org. Heart Rhythm Association (EHRA) and the European Cardiacwhich Arrhythmia patients are Society better candidates(ECAS), for AF published an Expert Consensus Statement to provide a state-of-the-artablation, these are review estimates of the and field are ofnot The Catheter and Surgical Ablation Pocket Guide was adapted from the HRS/EHRA/ECAS Expert based on large prospective clinical trials. catheter and surgical ablation of AF. The main objective Theof this only Expert absolute Consensus contraindications Statement for AF Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for is to improve patient care by providing a foundation of knowledgeablation identified for those by involved the consensus with writ- Catheter and Personnel, Policy, Procedures and Follow-Up. ing group were the presence of a left atrial catheter and surgical ablation of AF. This Expert Consensusthrombus Statement or the summarizes inability of a thepatient opin to- be ion of the Task Force members based on their experiencesystemically and a review anticoagulated of the literature. during and fol- Hugh Calkins, MD, FHRS David Haines MD, FHRS J. Lluis Mont, MD, FESC lowing the ablation procedure. Surgical Ablation Josep Brugada, MD, FESC Yoshito Iesaka, MD Fred Morady, MD This pocket guide provides a brief synopsis of information provided in the full-text con- Douglas Packer, MD, FHRS Warren Jackman, MD Koonlawee Nademanee, MD sensus statement. It does not contain all of the recommendations found in the executive Riccardo Cappato, MD, FESC Pierre Jais, MD Andrea Natale, MD, FHRS of Atrial Fibrillation summary or full-text consensus statement. The content herein is tailored toward the primary Shih-Ann Chen, MD, FHRS Hans Kottkamp, MD Carl Pappone, MD, PhD care clinician (family physician, internist, nurse practitioner, and physician’s assistant), car- Harry Crijns, MD, FESC Karl Heinz Kuck, MD, FESC Eric Prystowsky, MD, FHRS Adapted from the HRS/EHRA/ECAS Expert Consensus Statement on diovascular physicians and electrophysiology specialists, as well as trainees. For additional, Ralph Damiano, Jr., MD Bruce Lindsay, MD, FHRS Antonio Raviele, MD, FESC D. Wyn Davies, MD, FHRS Francis Marchlinski, MD Jeremy Ruskin, MD Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations more technical detail, the user should refer to the full-text consensus statement for exten- Michel Haissaguerre, MD Patrick McCarthy, MD Richard Shemin, MD for Personnel, Policy, Procedures and Follow-Up sive information, rationale, recommendations and caveats, which are carefully presented on our website at www.HRSonline.org. A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial www.HRSonline.org 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

Maintenance of Sinus Rhythm (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS).

Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ, Jr., Davies DW, Haines ➤ ➤ ➤ ➤ DE, Haissaguerre M, et al. HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical No (or minimal) Coronary artery Heart Hypertension heart disease disease failure 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 Flecainide Substantial Dofetilide Amiodarone Propafenone LVH Sotalol Dofetilide Sotalol fibrillation. HeartRhythm 2007 Jun;4(6):816-61. ➤ ➤ ➤ ➤ ➤ ➤ ➤

Amiodarone Catheter Catheter Catheter Endorsed and approved by the governing bodies of the American College of Cardiology, the No Yes Amiodarone Dofetilide ablation ablation ablation ➤ ➤ American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Flecainide Propafenone Amiodarone Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Sotalol

➤ ➤ ➤ Reprinted with permission Amiodarone Catheter Catheter ACC/AHA/ESC 2006 Guidelines for the Dofetilide ablation ablation ©2007 Heart Rhythm Society Management of Patients With Atrial Fibrillation ©2006, American Heart Association, Inc.