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, 8, 9, 10, 11, 12, 13, 14, 15, 16, 19, 20, 21, 22, 23, 24, 25, 26, 109 |
| Achievement of electrical isolation requires, at a minimum, assessment and demonstration of entrance block into the PV. | I | B-R | 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 19, 20, 21, 22, 23, 24, 25, 26, 109 | |
| Monitoring for PV reconnection for 20 minutes following initial PV isolation is reasonable. | IIa | B-R | 9, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120 | |
| Administration of adenosine 20 minutes following initial PV isolation using RF energy with reablation if PV reconnection might be considered. | IIb | B-R | 109, 111, 112, 113, 114, 120, 121, 122, 123, 124, 125, 126, 127, 128 | |
| Use of a pace-capture (pacing along the ablation line) ablation strategy may be considered. | IIb | B-R | 129, 130, 131, 132, 133 | |
| Demonstration of exit block may be considered. | IIb | B-NR | 134, 135, 136, 137, 138, 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, 141, 142, 143 |
| If linear ablation lesions are applied, operators should use mapping and pacing maneuvers to assess for line completeness. | I | C-LD | 19, 141, 142, 143, 144, 145, 146, 147, 148, 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, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161 | |
| When performing AF ablation with a force-sensing RF ablation catheter, a minimal targeted contact force of 5 to 10 grams is reasonable. | IIa | C-LD | 13, 14, 128, 162, 163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176, 177, 178 | |
| Posterior wall isolation might be considered for initial or repeat ablation of persistent or long-standing persistent AF. | IIb | C-LD | 21, 179, 180, 181, 182, 183, 184, 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, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161 | |
| DF-based ablation strategy is of unknown usefulness for AF ablation. | IIb | C-LD | 186, 187, 188, 189, 190, 191, 192, 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, 146, 147, 148, 149, 194, 195, 196, 197, 198, 199, 200, 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, 146, 147, 148, 149, 194, 195, 196, 197, 198, 199, 200, 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, 203, 204, 205, 206, 207, 208, 209, 210, 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, 196, 197, 212, 213, 214, 215, 216, 217, 218, 219, 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, 222, 223, 224, 225, 226, 227, 228, 229, 230, 231, 232, 233, 234, 235, 236, 237, 238, 239, 240, 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, 243, 244, 245, 246, 247, 248, 249, 250, 251, 252, 253, 254, 255, 256, 257, 258, 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, 261, 262, 263, 264, 265, 266, 267, 268, 269, 270, 271, 272, 273, 274, 275, 276, 277, 278, 279, 280, 281, 282, 283, 284, 285, 286, 287, 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, 261, 262, 263, 264, 265, 266, 267, 268, 269, 270, 271, 272, 273, 274, 275, 276, 277, 278, 279, 280, 281, 282, 283, 284, 285, 286, 287, 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, 277, 278, 289, 290, 291, 292, 293, 294, 295, 296, 297, 298, 299, 300, 301, 302, 303, 304, 305, 306, 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, 277, 278, 289, 290, 291, 292, 293, 294, 295, 296, 297, 298, 299, 300, 301, 302, 303, 304, 305, 306, 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, 309, 310, 311, 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, 309, 310, 311, 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, 314, 315, 316, 317, 318, 319, 320, 321, 322, 323, 324, 325, 326, 327, 328, 329, 330, 331, 332, 333, 334, 335 |
| It is recommended that RF power be reduced when creating lesions along the posterior wall near the esophagus. | I | C-LD | 68, 336, 337, 338, 339, 340, 341, 342, 343, 344, 345, 346, 347, 348, 349, 350, 351, 352, 353, 354, 355, 356, 357, 358, 359, 360, 361, 362, 363, 364, 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.