2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design 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), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society Hugh Calkins, MD, FACC, FHRS, FAHA; Karl Heinz Kuck, MD, FESC; Riccardo Cappato, MD, FESC; Josep Brugada, MD, FESC; A. John Camm, MD, PhD; Shih-Ann Chen, MD, FHRS§; ;Harry J.G. Crijns, MD, PhD, FESC; Ralph J. Damiano, Jr., MDٙ; D. Wyn Davies, MD, FHRS ;John DiMarco, MD, PhD, FACC, FHRS; James Edgerton, MD, FACC, FACS, FACCPٙ Kenneth Ellenbogen, MD, FHRS; Michael D. Ezekowitz, MD; David E. Haines, MD, FHRS; Michel Haissaguerre, MD; Gerhard Hindricks, MD; Yoshito Iesaka, MD§; Warren Jackman, MD, FHRS; Jose Jalife, MD, FHRS; Pierre Jais, MD; Jonathan Kalman, MD§; David Keane, MD; Young-Hoon Kim, MD, PhD§; Paulus Kirchhof, MD; George Klein, MD; Hans Kottkamp, MD; Koichiro Kumagai, MD, PhD§; Bruce D. Lindsay, MD, FHRSϱ; Moussa Mansour, MD; ;Francis E. Marchlinski, MD; Patrick M. McCarthy, MDٙ; J. Lluis Mont, MD, FESC; Fred Morady, MD Koonlawee Nademanee, MD; Hiroshi Nakagawa, MD, PhD, Andrea Natale, MD, FHRS¡; Stanley Nattel, MD; Douglas L. Packer, MD, FHRS; Carlo Pappone, MD, PhD; Eric Prystowsky, MD, FHRS; Antonio Raviele, MD, FESC; Vivek Reddy, MD; Jeremy N. Ruskin, MD; Richard J. Shemin, MDٙ; Hsuan-Ming Tsao, MD§; David Wilber, MD ٙSTS Representative §APHRS Representative ¡ACC Representative ϱAHA Representative TASK FORCE MEMBERS: Chairs: Hugh Calkins, MD, FACC, FHRS, FAHA, Chair, Johns Hopkins Hospital, Maryland, USA Karl Heinz Kuck, MD, FESC, Co-Chair, Allgemeines Krankenhaus St. Georg, Hamburg, GERMANY Riccardo Cappato, MD, FESC, Co-Chair, Arrhythmia and EP Center, IRCCS Policlinico San Donato, Milan, ITALY Section Chairs: Atrial Fibrillation: Definitions, Mechanisms, and Rationale for Ablation—Shih-Ann Chen, MD, FHRS, Taipei Veterans General Hospital, TAIWAN 1547-5271/$ -see front matter © 2012 Heart Rhythm Society, the European Heart Rhythm Association a registered branch of the European Society of Cardiology, and the European Cardiac Arrhythmia Society. All rights reserved. doi:10.1016/j.hrthm.2011.12.016 Calkins et al HRS/EHRA/ECAS Catheter and Surgical Ablation 633 Indications for Ablation and Patient Selection—Eric N. Prystowsky, MD, FHRS, The Care Group, LLC, Indiana, USA Techniques and Endpoints for Atrial Fibrillation—Karl Heinz Kuck, MD, FESC, Allgemeines Krankenhaus St. Georg, Hamburg, GERMANY Technologies and Tools—Andrea Natale, MD, FHRS, Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Texas, USA Other Technical Aspects—David E. Haines, MD, FHRS, Chair, William Beaumont Hospital, Michigan, USA Follow-up Considerations and Definitions for Success—Francis E. Marchlinski, MD, Hospital of the University of Pennsylvania, Pennsylvania, USA Outcomes and Efficacy of Catheter Ablation of Atrial Fibrillation—Hugh Calkins, MD, FACC, FHRS, FAHA, Johns Hopkins Hospital, Maryland, USA Complications of Atrial Fibrillation Ablation: Definitions, Incidence, Prevention and Management— D. Wyn Davies, MD, FHRS, St. Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UNITED KINGDOM Training Requirements and Competencies—Bruce D. Lindsay, MD, FHRS, Cleveland Clinic Foundation, Ohio, USA Surgical Ablation of Atrial Fibrillation—Ralph Damiano, Jr., MD, Washington University School of Medicine, Missouri, USA Clinical Trial Considerations—Douglas L. Packer, MD, FHRS, Mayo Foundation, Minnesota, USA Co-Authors: Josep Brugada, MD, FESC, Hospital Clinic, University of Barcelona, SPAIN A. John Camm, MD, PhD, St. George’s University of London, London, UNITED KINGDOM Harry J.G. Crijns, MD, PhD, FESC, University Hospital Maastricht, THE NETHERLANDS John DiMarco, MD, University of Virginia Health System, Virginia, USA James Edgerton, MD, FACC, FACS, FACCP, The Heart Hospital Baylor Plano and Cardiopulmonary Research, Science, and Technology Institute, Texas, USA Kenneth Ellenbogen, MD, Virginia Commonwealth University, Virginia, USA Michael D. Ezekowitz, MD, Jefferson Medical College, Pennsylvania, USA Michel Haissaguerre, MD, Université De Bordeaux, Hôpital Cardiologique, FRANCE Gerhard Hindricks, MD, University of Leipzig, Leipzig, GERMANY Yoshito Iesaka, MD, Tsuchiura Kyodo Hospital, JAPAN Warren M. Jackman, MD, FHRS, University of Oklahoma Health Science Center, Oklahoma, USA Pierre Jais, MD, Université De Bordeaux, Hôpital Cardiologique, FRANCE Jose Jalife, MD, University of Michigan, Michigan, USA Jonathan Kalman, MD, Royal Melbourne Hospital, Melbourne, AUSTRALIA David Keane, MD, St. Vincent’s University Hospital, Dublin, IRELAND Young-Hoon Kim, MD, PhD, Korea University Medical Center, Seoul, KOREA Paulus Kirchhof, MD, University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UNITED KINGDOM, and Department of Cardiology, University of Münster, Münster, GERMANY George Klein, University Hospital, London, Ontario, CANADA Hans Kottkamp, MD, FESC, Clinic Hirslanden Zurich, SWITZERLAND Koichiro Kumagai, MD, PhD, Fukuoka Sanno Hospital, JAPAN Moussa Mansour, MD, Massachusetts General Hospital, Massachusetts, USA Francis Marchlinski, MD, Hospital of the University of Pennsylvania, Ohio, USA Patrick McCarthy, MD, Northwestern Memorial Hospital, Illinois, USA J. Lluis Mont, MD, FESC Hospital Clinic, University of Barcelona, SPAIN 634 Heart Rhythm, Vol 9, No 4, April 2012 Fred Morady, MD, University of Michigan Health System, Michigan, USA Koonlawee Nademanee, MD, Pacific Rim EP Research Institute Center, California, USA Hiroshi Nakagawa, MD, PhD, University of Oklahoma Health Sciences Center, Oklahoma, USA Stanley Nattel, MD, Montreal Heart Institute, Quebec, CANADA Carlo Pappone, MD, PhD, Maria Cecilia Hospital, Cotignola, ITALY Antonio Raviele, MD, FESC, Umberto I Hospital, Venice, ITALY Vivek Reddy, MD, Mount Sinai School of Medicine, New York, USA Jeremy N. Ruskin, MD, Massachusetts General Hospital, Massachusetts, USA Richard J. Shemin, MD, David Geffen School of Medicine at UCLA, California, USA Hsuan-Ming Tsao, MD, National Yang Ming University Hospital, TAIWAN David Wilber, MD, FHRS, Loyola University Medical Center, Illinois, USA TABLE OF CONTENTS 3. INDICATIONS FOR CATHETER AND SURGICAL ABLATION OF ATRIAL 1. INTRODUCTION ....................................................635 FIBRILLATION.............................................................645 2. ATRIAL FIBRILLATION: DEFINITIONS, 4. TECHNIQUES AND ENDPOINTS FOR MECHANISMS, AND RATIONALE FOR ATRIAL FIBRILLATION ABLATION .................647 ABLATION ..............................................................636 4.1. Historical Considerations ................................647 2.1. Definitions........................................................636 4.2. Ablation Approaches Targeting the 2.2. Mechanisms of Atrial Fibrillation...................637 Pulmonary Veins .............................................647 2.3. Multiple Wavelet Hypothesis..........................638 4.3. Ablation Approaches Not Targeting the 2.4. Focal Triggers..................................................639 Pulmonary Veins .............................................647 2.5. Electrophysiology of the Pulmonary Veins....640 4.4. Task Force Consensus.....................................648 2.6. Frequency Gradients in Atrial Fibrillation 5. TECHNOLOGIES AND TOOLS............................649 Organization.....................................................640 5.1. Energy Sources—Radiofrequency Energy......649 2.7. Cardiac Autonomic Nervous System and 5.2. Contact Force Sensing Catheters and Systems.......650 Triggered Spontaneous Pulmonary Vein 5.3. Energy Sources—Cryoablation Energy ..........650 Firing......................................................................641 5.4. Ultrasound and Laser Ablation Systems ........650 2.8. Electrophysiologic Basis for Catheter 5.5. Multielectrode Circumferential Ablation Ablation of Atrial Fibrillation.........................642 Catheters ..........................................................650 2.9. Rationale for Eliminating Atrial Fibrillation 5.6. Electroanatomic Mapping Systems.................651 with Ablation ...................................................643 5.7. Robotic and Magnetic Catheter Navigation ...651 2.10. Mechanisms of Recurrence Following 5.8. Intracardiac Echocardiography........................651 Catheter or Surgical AF Ablation...................644 5.9. Pulmonary Vein Venography..........................651 2.11. Demographic Profile of AF Patients and 5.10. CT and/or MRI Scans and Rotational Risk Factors for Development of AF .............644 Angiography to Define the Anatomy of the 2.12. Genetics of AF: Relevance to AF ..................644 Atrium, PVs,