Table 2.
Indications for catheter (A and B) and surgical (C, D, and E) ablation of atrial fibrillation
| Recommendation | Class | LOE | References | |
|---|---|---|---|---|
| Indications for catheter ablation of atrial fibrillation | ||||
| A. Indications for catheter ablation of atrial fibrillation | ||||
| Symptomatic AF refractory or intolerant to at least one Class I or III antiarrhythmic medication | Paroxysmal: Catheter ablation is recommended. | I | A | 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 |
| Persistent: Catheter ablation is reasonable. | IIa | B-NR | 8, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 | |
| Long-standing persistent: Catheter ablation may be considered. | IIb | C-LD | 8, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 | |
| Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class I or III antiarrhythmic medication | Paroxysmal: Catheter ablation is reasonable. | IIa | B-R | 27, 28, 29, 30, 31, 32, 33, 34, 35 |
| Persistent: Catheter ablation is reasonable. | IIa | C-EO | ||
| Long-standing persistent: Catheter ablation may be considered. | IIb | C-EO | ||
| B. Indications for catheter atrial fibrillation ablation in populations of patients not well represented in clinical trials | ||||
| Congestive heart failure | It is reasonable to use similar indications for AF ablation in selected patients with heart failure as in patients without heart failure. | IIa | B-R | 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 |
| Older patients (>75 years of age) | It is reasonable to use similar indications for AF ablation in selected older patients with AF as in younger patients. | IIa | B-NR | 53, 54, 55, 56, 57, 58, 59 |
| Hypertrophic cardiomyopathy | It is reasonable to use similar indications for AF ablation in selected patients with HCM as in patients without HCM. | IIa | B-NR | 60, 61, 62 |
| Young patients (<45 years of age) | It is reasonable to use similar indications for AF ablation in young patients with AF (<45 years of age) as in older patients. | IIa | B-NR | 63, 64 |
| Tachy-brady syndrome | It is reasonable to offer AF ablation as an alternative to pacemaker implantation in patients with tachy-brady syndrome. | IIa | B-NR | 33, 34, 35 |
| Athletes with AF | It is reasonable to offer high-level athletes AF as first-line therapy due to the negative effects of medications on athletic performance. | IIa | C-LD | 27, 28, 65 |
| Asymptomatic AF⁎⁎ | Paroxysmal: Catheter ablation may be considered in select patients.⁎⁎ | IIb | C-EO | 66, 67 |
| Persistent: Catheter ablation may be considered in select patients. | IIb | C-EO | 68 | |
| Indications for surgical ablation of atrial fibrillation | ||||
| C. Indications for concomitant open (such as mitral valve) surgical ablation of atrial fibrillation | ||||
| Symptomatic AF refractory or intolerant to at least one Class I or III antiarrhythmic medication | Paroxysmal: Surgical ablation is recommended. | I | B-NR | 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82 |
| Persistent: Surgical ablation is recommended. | I | B-NR | 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82 | |
| Long-standing persistent: Surgical ablation is recommended. | I | B-NR | 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82 | |
| Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class I or III antiarrhythmic medication | Paroxysmal: Surgical ablation is recommended. | I | B-NR | 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82 |
| Persistent: Surgical ablation is recommended. | I | B-NR | 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82 | |
| Long-standing persistent: Surgical ablation is recommended. | I | B-NR | 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82 | |
| D. Indications for concomitant closed (such as CABG and AVR) surgical ablation of atrial fibrillation | ||||
| Symptomatic AF refractory or intolerant to at least one Class I or III antiarrhythmic medication | Paroxysmal: Surgical ablation is recommended. | I | B-NR | 83, 84, 85, 86, 87, 88 |
| Persistent: Surgical ablation is recommended. | I | B-NR | 83, 84, 85, 86, 87, 88 | |
| Long-standing persistent: Surgical ablation is recommended. | I | B-NR | 83, 84, 85, 86, 87, 88 | |
| Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class I or III antiarrhythmic medication | Paroxysmal: Surgical ablation is reasonable. | IIa | B-NR | 83, 84, 85, 86, 87, 88 |
| Persistent: Surgical ablation is reasonable. | IIa | B-NR | 83, 84, 85, 86, 87, 88 | |
| Long-standing persistent: Surgical ablation is reasonable. | IIa | B-NR | 83, 84, 85, 86, 87, 88 | |
| E. Indications for stand-alone and hybrid surgical ablation of atrial fibrillation | ||||
| Symptomatic AF refractory or intolerant to at least one Class I or III antiarrhythmic medication | Paroxysmal: Stand-alone surgical ablation can be considered for patients who have failed one or more attempts at catheter ablation and also for those who are intolerant or refractory to antiarrhythmic drug therapy and prefer a surgical approach, after review of the relative safety and efficacy of catheter ablation versus a stand-alone surgical approach. | IIb | B-NR | 83, 84, 85, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103 |
| Persistent: Stand-alone surgical ablation is reasonable for patients who have failed one or more attempts at catheter ablation and also for those patients who prefer a surgical approach after review of the relative safety and efficacy of catheter ablation versus a stand-alone surgical approach. | IIa | B-NR | 83, 84, 85, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103 | |
| Long-standing persistent: Stand-alone surgical ablation is reasonable for patients who have failed one or more attempts at catheter ablation and also for those patients who prefer a surgical approach after review of the relative safety and efficacy of catheter ablation versus a stand-alone surgical approach. | IIa | B-NR | 83, 84, 85, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103 | |
| It might be reasonable to apply the indications for stand-alone surgical ablation described above to patients being considered for hybrid surgical AF ablation. | IIb | C-EO | 103, 104, 105, 106, 107, 108 | |
AF = atrial fibrillation; LOE = Level of Evidence; HCM = hypertrophic cardiomyopathy.
⁎⁎
A decision to perform AF ablation in an asymptomatic patient requires additional discussion with the patient because the potential benefits of the procedure for the patient without symptoms are uncertain.