2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation

Calkins, Hugh; Hindricks, Gerhard; Cappato, Riccardo; Kim, Young Hoon; Saad, Eduardo; Aguinaga, Luis; Akar, Joseph G.; Badhwar, Vinay; Brugada, Josép; Camm, John; Chen, Peng Sheng; Chen, Shih Ann; Chung, Mina K.; Nielsen, Jens Cosedis; Curtis, Anne B.; Davies, D. Wyn; Day, John D.; d’Ávila, André; Groot, Natasja M.S. de; Biase, Luigi Di; Duytschaever, Mattias; Edgerton, James R.; Ellenbogen, Kenneth A.; Ellinor, Patrick T.; Ernst, Sabine; Fenelon, Guilherme; Gerstenfeld, Edward P.; Haines, David E.; Haı̈ssaguerre, Michel; Helm, Robert H.; Hylek, Elaine M.; Jackman, Warren M.; Jalife, José; Kalman, Jonathan M.; Kautzner, Josef; Kottkamp, Hans; Kuck, Karl Heinz; Kumagai, Koji; Lee, Richard; Lewalter, Thorsten; Lindsay, Bruce D.; Macle, Laurent; Mansour, Moussa; Marchlinski, Francis E.; Michaud, Gregory F.; Nakagawa, Hiroshi; Natale, Andrea; Nattel, Stanley; Okumura, Ken; Packer, Douglas L.; Pokushalov, Evgeny; Reynolds, Matthew R.; Sanders, Prashanthan; Scanavacca, Maurício; Schilling, Richard J.; Tondo, Claudio; Tsao, Hsuan Ming; Verma, Atul; Wilber, David J.; Yamane, Teiichi

doi:10.1016/j.hrthm.2017.05.012

Cited by 1,851 publications

(1,205 citation statements)

References 1,399 publications

(1,985 reference statements)

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“…While radiofrequency catheter ablation is effective for some patients with paroxysmal AF, the long‐term freedom from arrhythmia is limited and outcomes for patients with persistent AF are even worse 3. Surgical treatments for AF have traditionally shown better outcomes than radiofrequency ablation 4.…”

Section: Introductionmentioning

confidence: 99%

Intrapulmonary Vein Ablation Without Stenosis: A Novel Balloon‐Based Direct Current Electroporation Approach

Witt

Sugrue

Padmanabhan

et al. 2018

JAHA

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BackgroundCurrent thermal ablation methods for atrial fibrillation, including radiofrequency and cryoablation, have a suboptimal success rate. To avoid pulmonary vein (PV) stenosis, ablation is performed outside of the PV, despite the importance of triggers inside the vein. We previously reported on the acute effects of a novel direct current electroporation approach with a balloon catheter to create lesions inside the PVs in addition to the antrum. In this study, we aimed to determine whether the effects created by this nonthermal ablation method were associated with irreversible lesions and whether PV stenosis or other adverse effects occurred after a survival period.Methods and ResultsInitial and survival studies were performed in 5 canines. At the initial study, the balloon catheter was inflated to contact the antrum and interior of the PV. Direct current energy was delivered between 2 electrodes on the catheter in ECG‐gated 100 μs pulses. A total of 10 PVs were treated demonstrating significant acute local electrogram diminution (mean amplitude decrease of 61.2±19.8%). After the survival period (mean 27 days), computed tomography imaging showed no PV stenosis. On histologic evaluation, transmural, although not circumferential, lesions were seen in each treated vein. No PV stenosis or esophageal injury was present.ConclusionsIrreversible, transmural lesions can be created inside the PV without evidence of stenosis after a 27‐day survival period using this balloon‐based direct current ablation approach. These early data show promise for an ablation approach that could directly treat PV triggers in addition to traditional PV antrum ablation.

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Section: Introductionmentioning

confidence: 99%

Intrapulmonary Vein Ablation Without Stenosis: A Novel Balloon‐Based Direct Current Electroporation Approach

Witt

Sugrue

Padmanabhan

et al. 2018

JAHA

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“…However, none of the studies reported the long‐term risk of thromboembolic events. The major concerns of the use of LAA ablation are increased thromboembolic risk, perforation, and phrenic nerve injury 40. LAA isolation may lead to the formation of thrombus in the LAA due to decreased contractility 18, 41.…”

Section: Discussionmentioning

confidence: 99%

“…On the other hand, all studies included in this meta‐analysis made use of distal LAA isolation. Anticoagulation should be continued after the procedure, although concomitant ligation of the LAA may provide the added benefit of preventing thrombus formation and reducing the need for anticoagulation 40. Given the theoretical increased risk of stroke due to decreased contraction of the LAA, transesophageal echocardiography is usually performed around 6 months after the ablation to rule out the presence of thrombus 6, 41.…”

Section: Discussionmentioning

confidence: 99%

Left atrial appendage isolation in atrial fibrillation catheter ablation: A meta‐analysis

AlTurki

Huynh

Dawas

et al. 2018

Journal of Arrhythmia

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A significant proportion of patients’ experience recurrence of atrial fibrillation (AF) despite pulmonary venous isolation (PVI), especially those with persistent AF. Isolation of the left atrial appendage (LAA) may reduce AF recurrence. The aim of this study was to assess the efficacy of LAA isolation in addition to PVI compared with PVI alone. We conducted a comprehensive search of electronic databases, up to April 21st, 2017, for all studies comparing the effect LAA electrical isolation or ligation in addition to PVI, as opposed to PVI alone, on the recurrence of atrial fibrillation after catheter ablation. We used random‐effects meta‐analysis models to summarize the studies. One RCT and four observational studies enrolling 781 patients were retained. Four studies assessed the added effect of LAA catheter ablation, and one study evaluated the effect of LAA ligation with the aim of LAA electrical isolation. Four studies exclusively enrolled patients with persistent atrial fibrillation and one study predominantly enrolled patients with persistent atrial fibrillation. Follow‐up ranged from 12 to 15 months. The addition of LAA isolation to PVI reduced AF recurrence compared with the latter alone (odds ratio (OR) = 0.19; 95% confidence intervals (CI) = 0.10‐0.37; P < 0.00001). Left atrial appendage isolation was also associated with a reduction in AF recurrence after repeat ablation (OR = 0.40; CI = 0.25‐0.65; P = 0.0003). The addition of LAA isolation to PVI was associated with a decrease in AF recurrence in patients with persistent AF. Further studies are needed to assess the effect on long‐term risk of stroke.

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“…Although further study data are needed to best define the efficacy and safety of performing catheter ablation on patients taking uninterrupted Factor Xa inhibitors or direct thrombin inhibitors, there appears to be robust multicenter data in existence to impart a class I recommendation ablation with uninterrupted dabigatran (Class 1, level of evidence (LOE) A) or rivaroxaban (Class 1, LOE B), and a 2A recommendation for the other Xa inhibitors, for which specific clinical studies have either not been performed or are currently underway at this time. 10 Regarding anticoagulation during catheter ablation, heparin should be administered prior to or immediately following transseptal puncture during AF catheter ablation procedures, and should be adjusted to achieve and maintain an activated clotting time (ACT) of at least 300 s (Class I, LOE B). 10 A heparin loading dose should be administered initially, followed by a standard heparin infusion.…”

Section: Anticoagulation Therapymentioning

confidence: 99%

“…10 Regarding anticoagulation during catheter ablation, heparin should be administered prior to or immediately following transseptal puncture during AF catheter ablation procedures, and should be adjusted to achieve and maintain an activated clotting time (ACT) of at least 300 s (Class I, LOE B). 10 A heparin loading dose should be administered initially, followed by a standard heparin infusion. This year's consensus guidelines 10 on Catheter and Surgical Ablation of Atrial Fibrillation recommend that the ACT level be checked at 10-to 15-min intervals until therapeutic anticoagulation is achieved, and then at 15-to 30-min intervals for the duration of the procedure.…”

Section: Anticoagulation Therapymentioning

confidence: 99%

Atrial Fibrillation Catheter Ablation: Overcoming Complications and Improving Success

Mathew

2017

J Innov Cardiac Rhythm Manage

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ABSTRACT. Careful patient selection and optimization of the management of active medical conditions prior to proceeding with catheter ablation for atrial fibrillation (AF) is critical to reducing complications and improving ablation success. AF ablation performed on patients who have not been offered appropriate antiarrhythmic drug therapy must be tempered with the procedure risks, particularly for those patients having multiple comorbidities. The inability to comply with systemic anticoagulation for thromboembolic prophylaxis in AF is a contraindication to AF ablation, as premature termination of anticoagulation therapy can lead to catastrophic thromboembolic complications. Successful pulmonary vein isolation (PVI), the cornerstone of AF ablation, is demonstrated by entrance and exit block post ablation, with sustained absence of atrium-to-pulmonary vein conduction in both directions. Beyond PVI, there is no consensus for other endpoints for AF ablation, particularly in patients with persistent or longstanding persistent AF. Complications of PVI for AF have decreased in recent years as technology and knowledge in this field has evolved; however, the risks of cardiac tamponade, thromboembolic complications, esophageal injury, and pulmonary vein stenosis may still be formidable.

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2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation

Cited by 1,851 publications

References 1,399 publications

Intrapulmonary Vein Ablation Without Stenosis: A Novel Balloon‐Based Direct Current Electroporation Approach

Intrapulmonary Vein Ablation Without Stenosis: A Novel Balloon‐Based Direct Current Electroporation Approach

Left atrial appendage isolation in atrial fibrillation catheter ablation: A meta‐analysis

Atrial Fibrillation Catheter Ablation: Overcoming Complications and Improving Success

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