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EHRA Key References on Atrial fibrillation ablation

Latest Update 2013 December

Atrial Fibrillation



Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins . 

Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, Le Mouroux A, Le Metayer P, Clementy J. N Engl J Med 1998;339:659-666.

Landmark paper showing that the pulmonary veins (PV) often harbour the ectopic foci that are responsible for “focally-induced atrial fibrillation”, and that ablation of these foci is able to prevent AF recurrences. In this original article ablation of the ectopic foci itself was the goal of the procedure, which has now been abanboned because of its risks (PV) and frequent recurrences.

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design.

Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, DiMarco J, et al. Europace. 2012 Apr; 14(4):528-606.

2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association. 

Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P; ESC Committee for Practice Guidelines-CPG; Document Reviewers. Europace. 2012 Oct;14(10):1385-413.
Updated reviews and recommendations concerning current AF ablation indications, techniques, trial design and outcomes reporting. Major change is the elevation of the indication of AF ablation to Class I (level of evidence A) in selected patients.

Ablating persistent atrial fibrillation successfully. 

Krummen DE, Narayan SM. Curr Cardiol Rep. 2012 Oct;14(5):563-70. 

Excellent review about the challenges of long standing persistent atrial fibrillation ablation. 

Procedural Complications

Complications of catheter ablation of atrial fibrillation: a systematic review. 

Gupta A, Perera T, Ganesan A, Sullivan T, Lau DH, Roberts-Thomson KC, Brooks AG, Sanders P. Circ Arrhythm Electrophysiol. 2013 Dec;6(6):1082-8. 

„Catheter ablation of atrial fibrillation has a low incidence of periprocedural complications. The acute complication rate has decreased significantly in recent years.”

Mapping and ablation of left atrial tachycardias occurring after atrial fibrillation ablation. 

Gerstenfeld EP, Marchlinski FE. Heart Rhythm. 2007 Mar;4(3 Suppl):S65-72. 

This review provides a systematic approach to the evaluation, diagnosis, localization, and elimination of left atrial tachycardias occurring after atrial fibrillation ablation.

Microembolism and catheter ablation I: a comparison of irrigated radiofrequency and multielectrode-phased radiofrequency catheter ablation of pulmonary vein ostia. 

Haines DE, Stewart MT, Dahlberg S, Barka ND, Condie C, Fiedler GR, Kirchhof NA, Halimi F, Deneke T. Circ Arrhythm Electrophysiol. 2013 Feb;6(1):16-22. 

„Left atrial ablation with irrigated radiofrequency and multielecrode phased RF (PVAC) catheters in swine is associated with microbubble and microembolus production. Avoiding overlap of electrodes 1 and 10 on PVAC should reduce the microembolic burden associated with this procedure.”

Microembolism and catheter ablation II: effects of cerebral microemboli injection in a canine model. 

Haines DE, Stewart MT, Barka ND, Kirchhof N, Lentz LR, Reinking NM, Urban JF, Halimi F, Deneke T, Kanal E. Circ Arrhythm Electrophysiol.2013 Feb;6(1):23-30. 

„Cerebral embolization of air microbubbles or microparticulate debris that approximate the embolic sources from catheter ablation can create hyperintense diffusion weighted MRI (DWI) punctate lesions in a canine model. The location and size of the DWI/fluid attenuating inversion recovery lesions correlate with pathological findings.”

Incidence of asymptomatic intracranial embolic events after pulmonary vein isolation: comparison of different atrial fibrillation ablation technologies in a multicenter study. 

Herrera Siklódy C, Deneke T, Hocini M, Lehrmann H, Shin DI, Miyazaki S,Henschke S, Fluegel P, Schiebeling-Römer J, Bansmann PM, Bourdias T, Dousset V, Haïssaguerre M, Arentz T. J Am Coll Cardiol. 2011 Aug 9;58(7):681-8. 

The multielectrode phased RF ablation catheter is associated with a significantly higher incidence of subclinical intracranial embolic events than conventional irrigated RF or cryballoon catheters.

Periprocedural  Anticoagulation 

Prevention of periprocedural ischemic stroke and management of hemorrhagic complications in atrial fibrillation ablation under continuous warfarin administration. 

Kuwahara T, Takahashi A, Takahashi Y, Kobori A, Miyazaki S, Takei A, Fujino T,Okubo K, Takagi K, Fujii A, Takigawa M, Watari Y, Hikita H, Sato A, Aonuma K. J Cardiovasc Electrophysiol. 2013 May;24(5):510-5. 

„The continuation of warfarin during the periprocedural period of AF ablation could reduce the incidence of stroke without increasing hemorrhagic complications. When cardiac tamponade occurred with this approach, it was safely treated with PCC and vitamin K.”

Feasibility and safety of dabigatran versus warfarin for periprocedural anticoagulation in patients undergoing radiofrequency ablation for atrial fibrillation: results from a multicenter prospective registry. 

Lakkireddy D, Reddy YM, Di Biase L, Vanga SR, Santangeli P, Swarup V, Pimentel R, Mansour MC, D'Avila A, Sanchez JE, Burkhardt JD, Chalhoub F, Mohanty P, Coffey J, Shaik N, Monir G, Reddy VY, Ruskin J, Natale A.  J Am Coll Cardiol. 2012 Mar 27;59(13):1168-74. 

In this registry periprocedural dabigatran use significantly increased the risk of bleeding or thromboembolic complications compared with uninterrupted warfarin therapy.

Dabigatran vs warfarin for radiofrequency catheter ablation of atrial fibrillation. 

Kim JS, She F, Jongnarangsin K, Chugh A, Latchamsetty R, Ghanbari H, Crawford T, Suwanagool A, Sinno M, Carrigan T, Kennedy R, Saint-Phard W, Yokokawa M, Good E, Bogun F, Pelosi F Jr, Morady F, Oral H. Heart Rhythm. 2013Apr;10(4):483-9. 

In this case-control analysis, when held for approximately 24 hours before the procedure and resumed 4 hours after vascular hemostasis, dabigatran appears to be as safe and effective as uninterrupted warfarin for periprocedural anticoagulation in patients undergoing RFA of AF.

Procedural Imaging

Use of intracardiac echocardiography during atrial fibrillation ablation. 

Ruisi CP, Brysiewicz N, Asnes JD, Sugeng L, Marieb M, Clancy J, Akar JG.  Pacing Clin

Electrophysiol. 2013 Jun;36(6):781-8.

Intracardiac echocardiography ( ICE) is a real time imaging tool which may be used to directing transseptal puncture, to identify left atrial structures and to guide the manipulation of catheters. ICE may also be used to visualize the esophagus in real-time and to assist with early identification of procedural complications.


Impact of preprocedural imaging on outcomes of catheter ablation in patients with atrial fibrillation

Yokokawa M, Olgun H, Sundaram B, Chugh A, Latchamsetty R, Good E, Crawford T, Jongnarangsin K, Pelosi F Jr, Bogun F, Morady F, Oral H J Interv Card Electrophysiol. 2012 Sep;34(3):255-62.
Preprocedural imaging using computerized tomography (CT) or magnetic resonance imaging (MRI) with 3-D reconstruction does not appear to have an effect on procedural efficiency or clinical outcomes in patients who undergo catheter ablation for AF.

Impact of image integration on catheter ablation for atrial fibrillation using three-dimensional electroanatomic mapping: a meta-analysis. 

Liu SX, Zhang Y, Zhang XW. Pacing Clin Electrophysiol. 2012 Oct;35(10):1242-7. 

„The image integration using CartoMerge guiding catheter ablation for AF does not improve the main clinical outcomes significantly compared with that by Carto in centers with experienced operators.”

MRI of the left atrium: predicting clinical outcomes in patients with atrial fibrillation.

Daccarett M, McGann CJ, Akoum NW, MacLeod RS, Marrouche NF. Expert Rev Cardiovasc Ther. 2011 Jan;9(1):105-11.

Excellent review concerning the role of MRI for determining the stage of left atrial (LA) structural remodeling, the prediction of ablation success and the risk of embolic events from the pioneers of LA MRI in Utah.

Single-shot devices


Cryoablation of atrial fibrillation. 

Piccini JP, Daubert JP. J Interv Card Electrophysiol. 2011 Dec;32(3):233-42.

Comprehensive review for the development of cryoablation for AF, summarize the available evidence base for both the safety and efficacy of the procedure,  finally  discuss the relative advantages and disadvantages of cryoablation versus radiofrequency ablation.

Cryoballoon ablation of paroxysmal atrial fibrillation: 5-year outcome after single procedure and predictors of success.

Neumann T, Wójcik M, Berkowitsch A, Erkapic D, Zaltsberg S, Greiss H, Pajitnev D, Lehinant S, Schmitt J, Hamm CW, Pitschner HF, Kuniss M.  Europace. 2013 Aug;15(8):1143-9.

Sinus rhythm can be maintained in a substantial proportion of patients with paroxysmal AF even 5 years after circumferential PVI using cryoballoon ablation. The rate of decline in freedom from AF was highest within the first 12 months after the index procedure. The patients with enlarged left atrium and/or impaired renal function have lower outcome.

Efficacy and safety of atrial fibrillation ablation with phased radiofrequency energy and multielectrode catheters. 

Andrade JG, Dubuc M, Rivard L, Guerra PG, Mondesert B, Macle L, Thibault B,Talajic M, Roy D, Khairy P. Heart Rhythm.2012 Feb;9(2):289-96.

Additional ablation concepts beyond pulmonary vein isolation

Rotors and the dynamics of cardiac fibrillation. 

Pandit SV, Jalife J. Circ Res. 2013 Mar 1;112(5):849-62.

„The objective of this article is to present a broad review of the role of cardiac electric rotors and their accompanying spiral waves in the mechanism of cardiac fibrillation.”

Time- and frequency-domain analyses of atrial fibrillation activation rate: the optical mapping reference.

Berenfeld O, Ennis S, Hwang E, Hooven B, Grzeda K, Mironov S, Yamazaki M, Kalifa J, Jalife J. Heart Rhythm. 2011 Nov;8(11):1758-65. 

Dominant frequency values (frequency domain) of signals (uni or bi) correlates better with those  of optical signal than cycle length (time domain) values for the respective signals.

Time- and frequency-domain characteristics of atrial electrograms during sinus rhythm and atrial fibrillation.

Chang SH, Ulfarsson M, Chugh A, Yoshida K, Jongnarangsin K, Crawford T, Good E, Pelosi F Jr, Bogun F, Morady F, Oral H.  J Cardiovasc Electrophysiol. 2011 Aug;22(8):851-7. 

„Structural and functional properties of the atrial myocardium during AF contribute to electrogram complexity, which may indicate the presence of extra-PV mechanisms of AF.”

Pulmonary vein isolation with complex fractionated atrial electrogram ablation for paroxysmal and nonparoxysmal atrial fibrillation: A meta-analysis 

Hayward RM, Upadhyay GA, Mela T, Ellinor PT, Barrett CD, Heist EK, Verma A,Choudhry NK, Singh JP. Heart Rhythm. 2011 Jul;8(7):994-1000.

Patients with nonparoxysmal AF, addition of  complex fractionated atrila electrogram (CFAE) ablation to pulmonary vein isolation results in greater improvement in freedom from AF. No additional benefit of this combined approach was observed in patients with paroxysmal AF.

Relationship between complex fractionated electrograms (CFE) and dominant frequency (DF) sites and prospective assessment of adding DF-guided ablation to pulmonary vein isolation in persistent atrial fibrillation (AF). 

Verma A, Lakkireddy D, Wulffhart Z, Pillarisetti J, Farina D, Beardsall M, Whaley B, Giewercer D, Tsang B, Khaykin Y.  J Cardiovasc Electrophysiol. 2011 Dec;22(12):1309-16.

„DF and CFE regions overlap only about 50%. AF termination retrospectively occurred on overlapping CFE/DF sites where DF was above the mean.”

Combined dominant frequency and complex fractionated atrial electrogram ablation after circumferential pulmonary vein isolation of atrial fibrillation.

Kumagai K, Sakamoto T, Nakamura K, Nishiuchi S, Hayano M, Hayashi T, Sasaki T, Aonuma K, Oshima S.  J Cardiovasc Electrophysiol. 2013 Sep;24(9):975-83. 

„A combined high-DF and continuous CFAE site ablation in all chambers after circumferential PVI may be effective in the paroxysmal and persistent AF patients.”

Treatment of atrial fibrillation by the ablation of localized sources: CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial.

Narayan SM, Krummen DE, Shivkumar K, Clopton P, Rappel WJ, Miller JM. J Am Coll Cardiol. 2012 Aug 14;60(7):628-36

First clinical evidence of localized sources maintaining human atrial fibrillation and of focal rotor-ablation improving procedural outcome.

Outcome of ablation treatment

Long-term outcomes of catheter ablation of atrial fibrillation: a systematic review and meta-analysis

Ganesan AN, Shipp NJ, Brooks AG, Kuklik P, Lau DH, Lim HS, Sullivan T, Roberts-Thomson KC, Sanders P.  J Am Heart Assoc. 2013 Mar 18;2(2)

„Although significant heterogeneity is seen with single procedures, long-term freedom from atrial arrhythmia can be achieved in some patients, but multiple procedures may be required”.

Predictors of atrial fibrillation recurrence after radiofrequency catheter ablation: a systematic review. 

Balk EM, Garlitski AC, Alsheikh-Ali AA, Terasawa T, Chung M, Ip S. J Cardiovasc Electrophysiol. 2010 Nov;21(11):1208-16.

Persistent AF can be clinically useful proxy for a combination of confounded variables, none of which alone  as gender, age, left atrial diameter, ejection fraction etc. is an independent predictor of AF recurrence.

Catheter ablation for atrial fibrillation: are results maintained at 5 years of follow-up?

Weerasooriya R, Khairy P, Litalien J, Macle L, Hocini M, Sacher F, Lellouche N, Knecht S, Wright M, Nault I, Miyazaki S, Scavee C, Clementy J, Haissaguerre M, Jais P. J Am Coll Cardiol. 2011 Jan 11;57(2):160-6.

Long term arrhythmia-free survival is acceptable (63% at 5 years after a median of 2 procedures), but a steady decline is observed over the years necessitating close follow-up.

Long-term success and follow-up after atrial fibrillation ablation.

Kircher S, Hindricks G, Sommer P. Curr Cardiol Rev. 2012 Nov;8(4):354-61. Review. 

„There is a clear correlation between the intensity of the monitoring strategy and the sensitivity for it to detect arrhythmia recurrences. Furthermore, several clinical studies assessing the long-term efficacy of catheter ablation procedures have reported late AF recurrences in patients who were initially considered responders to catheter ablation. In certain subsets of patients, precise long-term monitoring may help to guide therapy, e.g. patients in whom withdrawal of antithrombotic therapy may be considered if they are free of arrhythmia recurrences.”

Atrial arrhythmia burden on long-term monitoring in asymptomatic patients late after atrial fibrillation ablation. 

Winkle RA, Mead RH, Engel G, Kong MH, Patrawala RA. Am J Cardiol. 2012 Sep 15;110(6):840-4.

„Given the longer duration of monitoring, pacemakers detected more AF than 7-day monitors.”