Table 3.
Atrial fibrillation ablation: strategies, techniques, and endpoints
| Recommendation | Class | LOE | References | |
|---|---|---|---|---|
| PV isolation by catheter ablation | Electrical isolation of the PVs is recommended during all AF ablation procedures. | I | A | [7–16, 19–26, 109] |
| Achievement of electrical isolation requires, at a minimum, assessment and demonstration of entrance block into the PV. | I | B-R | [7–16, 19–26, 109] | |
| Monitoring for PV reconnection for 20 min following initial PV isolation is reasonable. | IIa | B-R | [9, 110–120] | |
| Administration of adenosine 20 min following initial PV isolation using RF energy with reablation if PV reconnection might be considered. | IIb | B-R | [109, 111–114, 120–128] | |
| Use of a pace-capture (pacing along the ablation line) ablation strategy may be considered. | IIb | B-R | [129–133] | |
| Demonstration of exit block may be considered. | IIb | B-NR | [134–139] | |
| Ablation strategies to be considered for use in conjunction with PV isolation | If a patient has a history of typical atrial flutter or typical atrial flutter is induced at the time of AF ablation, delivery of a cavotricuspid isthmus linear lesion is recommended. | I | B-R | [140–143] |
| If linear ablation lesions are applied, operators should use mapping and pacing maneuvers to assess for line completeness. | I | C-LD | [19, 141–149] | |
| If a reproducible focal trigger that initiates AF is identified outside the PV ostia at the time of an AF ablation procedure, ablation of the focal trigger should be considered. | IIa | C-LD | [150–161] | |
| When performing AF ablation with a force-sensing RF ablation catheter, a minimal targeted contact force of 5 to 10 g is reasonable. | IIa | C-LD | [13, 14, 128, 162–178] | |
| Posterior wall isolation might be considered for initial or repeat ablation of persistent or long-standing persistent AF. | IIb | C-LD | [21, 179–185] | |
| Administration of high-dose isoproterenol to screen for and then ablate non-PV triggers may be considered during initial or repeat AF ablation procedures in patients with paroxysmal, persistent, or long-standing persistent AF. | IIb | C-LD | [150–161] | |
| DF-based ablation strategy is of unknown usefulness for AF ablation. | IIb | C-LD | [186–193] | |
| The usefulness of creating linear ablation lesions in the right or left atrium as an initial or repeat ablation strategy for persistent or long-standing persistent AF is not well established. | IIb | B-NR | [19, 20, 142, 145–149, 194–201] | |
| The usefulness of linear ablation lesions in the absence of macroreentrant atrial flutter is not well established. | IIb | C-LD | [19, 20, 142, 145–149, 194–201] | |
| The usefulness of mapping and ablation of areas of abnormal myocardial tissue identified with voltage mapping or MRI as an initial or repeat ablation strategy for persistent or long-standing persistent AF is not well established. | IIb | B-R | [179, 202–211] | |
| The usefulness of ablation of complex fractionated atrial electrograms as an initial or repeat ablation strategy for persistent and long-standing persistent AF is not well established. | IIb | B-R | [19, 20, 195–197, 212–220] | |
| The usefulness of ablation of rotational activity as an initial or repeat ablation strategy for persistent and long-standing persistent AF is not well established. | IIb | B-NR | [221–241] | |
| The usefulness of ablation of autonomic ganglia as an initial or repeat ablation strategy for paroxysmal, persistent, and long-standing persistent AF is not well established. | IIb | B-NR | [19, 89, 242–259] | |
| Nonablation strategies to improve outcomes | Weight loss can be useful for patients with AF, including those who are being evaluated to undergo an AF ablation procedure, as part of a comprehensive risk factor management strategy. | IIa | B-R | [260–288] |
| It is reasonable to consider a patient's BMI when discussing the risks, benefits, and outcomes of AF ablation with a patient being evaluated for an AF ablation procedure. | IIa | B-R | [260–288] | |
| It is reasonable to screen for signs and symptoms of sleep apnea when evaluating a patient for an AF ablation procedure and to recommend a sleep evaluation if sleep apnea is suspected. | IIa | B-R | [270, 276–278, 289–307] | |
| Treatment of sleep apnea can be useful for patients with AF, including those who are being evaluated to undergo an AF ablation procedure. | IIa | B-R | [270, 276–278, 289–307] | |
| The usefulness of discontinuation of antiarrhythmic drug therapy prior to AF ablation in an effort to improve long-term outcomes is unclear. | IIb | C-LD | [308–312] | |
| The usefulness of initiation or continuation of antiarrhythmic drug therapy during the postablation healing phase in an effort to improve long-term outcomes is unclear. | IIb | C-LD | [308–312] | |
| Strategies to reduce the risks of AF ablation | Careful identification of the PV ostia is mandatory to avoid ablation within the PVs. | I | B-NR | [313–335] |
| It is recommended that RF power be reduced when creating lesions along the posterior wall near the esophagus. | I | C-LD | [68, 336–365] | |
| It is reasonable to use an esophageal temperature probe during AF ablation procedures to monitor esophageal temperature and help guide energy delivery. | IIa | C-EO | [68, 336, 345, 365] |
AF atrial fibrillation, LOE Level of Evidence, PV pulmonary vein, RF radiofrequency, MRI magnetic resonance imaging, BMI body mass index