Catheter Ablation for
atrial fibrillation

Procedural Consideration
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1. Patient Factors and Ablation Outcomes
Duration & Types of AF
Andrade et al. JAMA Netw Open. 2020 Jul 1;3(7):e208748. Andrade et al. JAMA Netw Open. 2020 Jul 1;3(7):e208748.
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
 NEW  Duration Based Classification

Paroxysmal continuous AF episode lasting longer than 30s but terminating spontaneously or with intervention within 7 days of onset.

EARLY Paroxysmal --Paroxysmal AF that terminates within 24hrs of onset.

Persistent continuous AF episode lasting longer than 7 days but <1 year

EARLY Persistent --Persistent AF that lasts less then 3 months.
Long-standing Persistent continuous AF episode lasting longer than 1 year, in whom rhythm control management is being pursued.

Permanent AF for which a therapeutic decision has been made not to pursue sinus rhythm restoration.
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
Obesity adversely impacts
ablation outcome and complications.
Winkle et al. Heart Rhythm. 2017 Jun;14(6):819-827.
Winkle et al. Heart Rhythm. 2017 Jun;14(6):819-827.
ALCOHOL
Takahashi et al. Circ Arrhythm Electrophysiol. 2021 Jun;14(6):e009770.
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
Types of AF, duration of AF, and comorbidities impact the outcome of AF ablation.
2. Perioperative Management
Pre-procedural Imaging is reasonable.
Marrouche et al. JAMA. 2014;311(5):498-506.
Marrouche et al. JAMA. 2014;311(5):498-506.
 PRE-Ablation  OAC 1/2
Minimum of 3-wk therapeutic OAC before ablation
is recommended in
1. HIGH Stroke risk by CHA2DS2-VASc
= CHA2DS2-VASc≥2 in Female or CHA2DS2-VASc≥1 in Male

2. Low-Intermediate Stroke risk by CHA2DS2-VASc plus other risks
= CHA2DS2-VASc≥1 in Female or CHA2DS2-VASc≥0 in Male
PLUS Other high stroke risks features (i.e. HCM, Amyloidosis, etc.)
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
 PRE-Ablation  OAC 2/2
No Interruption of OAC before ablation is recommended.
Minimal Interruption is reasonable.
TEE or CT within 48hrs
is reasonable for exclusion of atrial thrombus.
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
van Vugt et al. Europace. 2021 Dec 7;23(12):1961-1969.
van Vugt et al. Europace. 2021 Dec 7;23(12):1961-1969.
 Peri-Ablation  Anticoagulation
IV Heparin to maintain
activated clotting time (ACT) of >300 seconds
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
OAC POST-Ablation 
Things to Consider
No RCTs on optimal OAC strategy after ablation.
Symptom is not a reliable predictor for AF.
Ablation itself has not been shown to reduce stroke.
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
OAC POST-Ablation 
Candidates for OAC Discontinuation
Low Stroke Risk
After 2 months; regardless of ablation result.
Intermediate Stroke Risk
After 12 months in the absence of AF.
High Stroke Risk
Should NOT be discontinued.
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
1. OAC Consideration before and after ablation is by stroke risk.
2. May use continous or minimal interruption strategy for periop OAC.
3. Technical Consideration
Pulmonary Veins are the main source of ectopic foci initiating AF.
Haïssaguerre et al. N Engl J Med. 1998 Sep 3;339(10):659-66.
Kistler et al. JAMA. 2023;329(2):127–135.
Kuck et al. N Engl J Med. 2016 Jun 9;374(23):2235-45.
Ablation Strategy beyond PVI.
Verma et al. N Engl J Med. 2015 May 7;372(19):1812-22.
Nademanee et al. J Am Coll Cardiol 2004;43:2044–53.
Kistler et al. JAMA. 2023;329(2):127–135.
Marrouche et al. JAMA. 2022;327(23):2296-2305.
Ablation Strategy beyond PVI is of UNCLEAR benefits.
#LessIsMore
Verma et al. N Engl J Med. 2015 May 7;372(19):1812-22.
Kistler et al. JAMA. 2023;329(2):127–135.
Marrouche et al. JAMA. 2022;327(23):2296-2305.
Andrade et al. Circulation. 2019 Nov 26;140(22):1779-1788.
Reddy et al. N Engl J Med. 2023 Nov 2;389(18):1660-1671.
Pulmonary Vein Isolation is required.
4. Complications
Banali K. JACC 2023.
Zhang and Bian. BMC Neurol 20, 16 (2020).
Circulation: Arrhythmia and Electrophysiology. 2017;10:e005579.
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
Serious complication such as AE fistula is rare but required attentive and aggressive management.
5. How to assess ablation outcomes
Steinberg et al. Heart Rhythm. 2021 Sep;18(9):1463-1470.
TWO MONTHS
of blanking period is now recommended; rather than 3 months. 2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
Ablation Outcomes 
Parameters to Assess
AF Recurrence
AF Burden
AF Progression
Symptoms Improvemnt
LVEF and HF Parameters
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
1. Assess outcomes 2 months after ablation.
2. Outcomes include frequency, burden, symptoms, progression, LVEF, and HF parameters.
6. Why does AF recur after ablation?
Sørensen et al. Circ Arrhythm Electrophysiol. 2021 May;14(5):e009573.
2024 EHRA/HRS/APHRS/LHRS expert consensus statement on ablation of AF
Santangeli et al. Heart Rhythm 2017.
Benali et al. Circ Arrhythm Electrophysiol. 2023.
AF recurs after ablation can be caused by PV reconnection, epicardial connection, and non-PV triggers.
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