Atrial fibrillation catheter ablation: Difference between revisions

Latest revision as of 03:26, 14 December 2022


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Anahita Deylamsalehi, M.D.[3] Vendhan Ramanujam M.B.B.S [4] Laith Adnan Allaham, M.D.[5]

Overview

In patients with atrial fibrillation where rate control drugs are ineffective and it is not possible to restore sinus rhythm using cardioversion, non-pharmacological alternatives are available. One of the techniques used is called catheter ablation, where the bundle of cells that pace the heart in the atrioventricular node, are destroyed using radiofrequency energy source, the dominant energy source for catheter ablation. Cryoablation has more recently been developed as a tool for atrial fibrillation (AF) ablation procedures. Other energy sources and tools are in various stages of development and/or clinical investigation. There are three classes of indications for using catheter ablation for atrial fibrillation (AF). The cornerstone for most atrial fibrillation ablation procedures are ablation strategies that target the pulmonary veins and/or pulmonary vein antrum while electrical isolation is the goal. Due to high risk of thromboembolism in patients with atrial fibrillation, careful attention and starting anticoagulation in atrial fibrillation patients before, during, and after ablation is important. Moreover, possible complications and adverse effects associated with catheter ablation in atrial fibrillation patients should be considerd.

Indications for Catheter and Surgical Ablation

The indications of ablation among patients with atrial fibrillation are stratified as class I, class IIa, class IIb, and class III.^[1]
One of the primary indications (class I) of ablation among patients with atrial fibrillation is the presence of symptomatic atrial fibrillation, which is refractory or intolerant to at least one class I or III antiarrhythmic medication.^[2]
Balloon-based ultrasound ablation and laser based ablation systems have also been developed for ablation of atrial fibrillation (AF).^[3]^[4]^[5]^[6]^[7]

Class I Indications

In symptomatic paroxysmal atrial fibrillation patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, catheter ablation is recommended.^[2]

Class IIa Indications

In symptomatic persistent atrial fibrillation patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, catheter ablation is reasonable.^[1]
In symptomatic paroxysmal atrial fibrillation patients, prior to initiation of antiarrhythmic drug therapy with either class I or III antiarrhythmic agent, catheter ablation is reasonable.
In patients who are undergoing surgery for other indications with symptomatic paroxysmal atrial fibrillation, refractory or intolerant to at least one class I or III antiarrhythmic medication, surgical ablation is reasonable.
In patients who are undergoing surgery for other indications with symptomatic persistent AF, refractory or intolerant to at least one class I or III antiarrhythmic medication, surgical ablation is reasonable.
In patients who are undergoing surgery for other indications with symptomatic longstanding persistent atrial fibrillation, refractory or intolerant to at least one class I or III antiarrhythmic medication, surgical ablation is reasonable.
In patients who are undergoing surgery for other indications with symptomatic paroxysmal atrial fibrillation prior to initiation of antiarrhythmic drug therapy with either class I or III antiarrhythmic agent, surgical ablation is reasonable.
In patients who are undergoing surgery for other indications with symptomatic persistent AF prior to initiation of antiarrhythmic drug therapy with either class I or III antiarrhythmic agent, surgical ablation is reasonable.

Class IIb Indications

In symptomatic longstanding persistent atrial fibrillation patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, catheter ablation may be considered.^[1]
In patients with symptomatic persistent atrial fibrillation prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication, catheter ablation may be considered.
In patients with symptomatic longstanding persistent atrial fibrillation prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication, catheter ablation may be considered.
In patients who are undergoing surgery for other indications with symptomatic longstanding persistent atrial fibrillation prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic agent, surgical ablation may be considered.
In symptomatic paroxysmal atrial fibrillation patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, stand alone surgical ablation may be considered if they have not failed catheter ablation but prefer a surgical approach.
In symptomatic paroxysmal atrial fibrillation patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, stand alone surgical ablation may be considered if they have failed one or more attempts at catheter ablation.
In symptomatic persistent atrial fibrillation patients who are either refractory or intolerant to at least one tion|class I or III antiarrhythmic medication]], stand alone surgical ablation may be considered if they have not failed catheter ablation but prefer a surgical approach.
In symptomatic persistent atrial fibrillation patients who are either refractory or intolerant to at least one tion|class I or III antiarrhythmic medication]], stand alone surgical ablation may be considered if they have failed one or more attempts at catheter ablation.
In symptomatic longstanding persistent atrial fibrillation patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, stand alone surgical ablation may be considered if they have not failed catheter ablation but prefer a surgical approach.
In symptomatic longstanding persistent atrial fibrillation patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, stand alone surgical ablation may be considered if they have failed one or more attempts at catheter ablation.

Class III Indications

In symptomatic paroxysmal or persistent or longstanding persistent atrial fibrillation patients, prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic agent, stand alone surgical ablation is not recommended.^[1]

Recommendations Regarding Catheter Ablation Technique

The cornerstone for most atrial fibrillation ablation procedures are ablation strategies that target the pulmonary veins and/or pulmonary vein antrum.^[8]^[9]
While targeting the pulmonary veins, electrical isolation should be the goal.^[8]
Electrical isolation requires, at a minimum, assessment and demonstration of entrance block into the pulmonary vein.^[8]^[9]
Monitoring for pulmonary vein reconduction for 20 minutes following initial pulmonary vein isolation should be considered.
Careful identification of the pulmonary vein ostia is mandatory to avoid ablation within the pulmonary veins.
If a focal trigger is identified outside a pulmonary vein at the time of an atrial fibrillation ablation procedure, ablation of that focal trigger should be considered.
If additional linear lesions are applied, operators should consider using mapping and pacing maneuvers to assess for line completeness.
Ablation of the cavotricuspid isthmus (fibrous tissue in the lower right atrium between the inferior vena cava and the |tricuspid valve) is recommended in patients with a history of typical atrial flutter or inducible cavotricuspid isthmus dependent atrial flutter.^[9]
If patients with long standing persistent atrial fbrillation are approached, operators should consider more extensive ablation based on linear lesions or complex fractionated electrograms.
It is recommended that radiofrequency power be reduced when creating lesions along the posterior wall near the esophagus.

Radiofrequency Ablation

In patients with symptomatic paroxysmal atrial fibrillation who did not tolerate medications or when medications are not successful, radiofrequency ablation is recommended.^[2]
To control rate it is possible to destroy the bundle of cells connecting the upper and lower chambers of the heart - the atrioventricular node - which regulates heart rate, and to implant a pacemaker instead.^[7]
A more complex technique, which avoids the need for a pacemaker, involves ablating groups of cells near the pulmonary veins where atrial fibrillation is thought to originate, or creating more extensive lesions in an attempt to prevent atrial fibrillation from establishing itself.^[7]
Ablation is a newer technique and has shown some promise for cases of recurrent atrial fibrillation that are unresponsive to conventional treatments. Radiofrequency ablation (RFA) uses radiofrequency energy to destroy abnormal electrical pathways in heart tissue.
Radiofrequency energy is delivered by way of a transvenous electrode catheter. The energy emitting probe (electrode) is placed into the heart through a catheter inserted into veins in the groin or neck.
Electrodes that can detect electrical activity from inside the heart are also inserted, and the electrophysiologist uses these to map an area of the heart in order to locate the abnormal electrical activity before eliminating the responsible tissue.
Most atrial fibrillation ablations consist of isolating the electrical pathways from the pulmonary veins (PV), which are located on the posterior wall of the left atrium. All other veins from the body (including neck and groin) lead to the right atrium, so in order to get to the left atrium the catheters must get across the atrial septum. This is done by piercing a small hole in the septal wall (transseptal approach). Once the catheter is in the left atrium, the physician may perform Wide Area Circumferential Ablation (WACA) to electrically isolate the pulmonary veins from the left atrium.^[10]^[11]
Some more recent approaches to ablating atrial fibrillation is to target sites that are particularly disorganized in both atria as well as in the coronary sinus (CS). The aforementioned sites are termed Complex Fractionated Atrial Electrogram (CFAE) sites.^[12]
It is believed by some that the CFAE sites are the cause of atrial fibrillation, or a combination of the pulmonary veins and CFAE sites are to blame.
Most tissues exposed to temperatures of 50 C or higher for more than several seconds will show irreversible coagulation necrosis, and evolve into non-conducting myocardial scar.
The following factors promote the formation of larger lesions and improve procedure efficacy:
- High power delivery
- Good electrode–tissue contact
- Adequate ablation duration
Significant complications can occur during atrial fibrillation ablation if high radiofrequency power is administered in an uncontrolled fashion.
The increased risk of atrial fibrillation ablation compared to ablation of other arrhythmias may be attributed to the great surface area of tissue ablated, the large cumulative energy delivery, the risk of systemic thromboembolism, and the close location of structures susceptible to collateral injury, such as phrenic nerve, pulmonary veins, and esophagus.
Thrombus, char formation and intramural steam pops can also occur.
Conventional radiofrequency electrodes were employed earlier. But comparative trials against conventional radiofrequency electrodes have demonstrated that irrigated tip and large tip radiofrequency technologies have increased efficacy and decreased procedure duration.^[13]

Cryoablation

Cryoablation is recommended when point by point radiofrequency ablation is not proper in atrial fibrillation patients.^[2]
Cryoablation is a new technique which uses cryothermal energy as an alternative energy source. In cryoablation, tissue freezing coolant, liquid nitrous oxide is delivered under pressure through a catheter where it changes to gas, resulting in cooling of surrounding tissue. Tissue injury results from tissue freezing with a creation of ice crystals within the cell that disrupts cell membranes and interrupts both cellular metabolism and any electrical activity in that cell. Interruption of microvascular perfusion also produces cell death by interrupting blood flow.^[14]
More recently, a number of point-by-point and balloon-based cryoablation systems have been developed.^[14]^[15]
Point-by-point cryoablation approach is proved to be associated with low complication rate, but the procedure is lengthy, and the long-term efficacy is limited. This ultimately paved way for the development of a cryoablation balloon ablation catheter.
Regional blood flow around the tip of the catheter or balloon influences the achievement of optimal cryoablation. Continuous blood flow reduces the chance of achieving a full-thickness cryoablation. Because of this, complete vein occlusion is required during the procedure.

Ultrasound Ablation

Although radiofrequency ablation and cryoablation are the two standard ablation systems used for catheter ablation of atrial fibrillation today, balloon-based ultrasound ablation have also been developed for atrial fibrillation ablation.^[16]^[17]
The first of the balloon ablation systems to be approved for clinical use is the focused ultrasound ablation system that uses high intensity focused ultrasound (HIFU).^[16]^[17]

Laser Ablation

Laser balloon ablation could be considered when radiofrequency ablation is not effective or tolerated.^[2]
Balloon based laser ablation system involving a compliant balloon ablation catheter are being developed through which arcs of laser energy are delivered under visual guidance.^[18]^[6]
Small clinical trials have demonstrated the safety and effectiveness of this ablation system, which is now approved for use in Europe and is entering a pivotal randomized clinical trial in the United States.^[18]^[6]

Anticoagulation Strategies

Atrial fibrillation patients are at increased risk of thromboembolism during, immediately following, and for several weeks to months after their ablation. Thus careful attention and starting anticoagulation in atrial fibrillation patients before, during, and after ablation for atrial fibrillation is important to avoid the occurrence of a thromboembolic events.

Pre Ablation

In patients who have atrial fibrillation for 48 hours or longer or for an unknown duration, three weeks of systemic anticoagulants at a therapeutic level prior to the procedure is required.^[19]
Prior to the ablation procedure a transesophageal echocardiography (TEE) should be performed in them.
Transesophageal echocardiography (TEE) in atrial fibrillation patients who have sinus rhythm at the time of ablation or patients with current atrial fibrillation who also had atrial fibrillaton for 48 hours or less prior to atrial fibrillation ablation may be considered, but it is not mandatory.
A left atrial thrombus found during transesophageal echocardiography (TEE) is a contraindication for catheter ablation of atrial fibrillation.
Catheter ablation of trial fibrillation on a patient who is therapeutically anticoagulated with warfarin should also be considered.^[19]

During Ablation

Heparin should be administered prior to or immediately following transseptal puncture during atrial fibrillation ablation procedures.^[20]
Atrial fibrillation ablation in a patient who is systemically anticoagulated with warfarin does not alter the need for intravenous heparin to maintain a therapeutic activated clotting time (300 to 400 seconds) during the procedure.
Administration of protamine following ablation to reverse heparin should be considered.

Post Ablation

In patients who are not therapeutically anticoagulated with warfarin at the time of atrial fibrillation ablation, low molecular weight heparin or intravenous heparin should be used to resume the systemic anticoagulation with warfarin following atrial fibrillation ablation.
Initiation of a direct thrombin or factor Xa inhibitor after ablation may be considered as an alternative post procedure anticoagulation strategy.^[21]
A reduction in the dose of low molecular weight heparin (0.5 mg/kg) should be considered because of the increased risk of post procedure bleeding following a full dose (1 mg/kg bid).
Systemic anticoagulation with warfarin or a direct thrombin or factor Xa inhibitor is recommended for at least two months following an atrial fibrillation ablation procedure. But decisions regarding the continuation of systemic anticoagulation for more than two months following ablation should be based on the patients risk factors for stroke.
Discontinuation of systemic anticoagulation therapy post ablation is not recommended in patients who are at high risk of stroke.
Patients in whom discontinuation of systemic anticoagulation is being considered should consider undergoing continuous ECG monitoring to screen for asymptomatic atrial fibrillation.

Outcomes and Efficacy of Catheter Ablation

Efficacy and risks of catheter ablation of atrial fibrillation are areas of active debate.^[22]
A worldwide survey of the outcomes of 8745 ablation procedures demonstrated a 52% success rate (ranging from 14.5% to 76.5% among centers), with an additional 23.9% of patients becoming asymptomatic with addition of an antiarrhythmic medication.^[23]
- In 27.3% of patients, more than one procedure was required to attain these results.
- There was at least one major complication in 6% of patients.
A thorough discussion of results of catheter ablation was published in 2007. ^[24]
- It notes that results are widely variable, due in part to differences in technique, follow-up, definitions of success, use of antiarrhythmic therapy, and in experience and technical proficiency.

Prevention of Recurrence After Ablation

NICE guideline updated in 2021 recommends to use antiarrhythmic agents in order to prevent atrial fibrillation recurrence after ablation.^[2]
It is important to consider patient's preference and side effects before starting antiarrhythmic agents.
3 months after starting antiarrhythmic agents to prevent atrial fibrillation recurrence, patients should be evaluated and necessicity for continuing antiarrhythmic agents should be assessed again.^[2]

Complications of Catheter Ablation

Catheter ablation of atrial fibrillation (AF) is one of the most complex interventional electrophysiologic procedures. Therefore the risk associated with atrial fibrillation (AF) ablation is higher. The following are complications associated with catheter ablation of atrial fibrillation (AF).^[25]^[26]^[27]

Atrio-esophageal fistula and esophageal injury
Bleeding
Cardiac perforation
Cardiac tamponade
Deep sternal wound infection/mediastinitis following cardiac surgery
Gastric motility/pyloric spasm disorders
Myocardial infarction
Pericarditis
Phrenic nerve paralysis
Pulmonary vein stenosis
Silent cerebral embolism
Stroke or Transient ischemic attack (TIA) post ablation
Unanticipated adverse device effect
Vagal nerve injury
Vascular access complications like hematoma, AV fistula and pseudoaneurysm

2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society^[28]

Recommendation for Catheter Ablation in HF Referenced studies that support the new recommendation are summarized in Online Data Supplement 7

Class IIb
1. AF catheter ablation may be reasonable in selected patients with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF.S6.3.4-1,S6.3.4-2NEW: New evidence, including data on improved mortality rate, has been published for AF catheter ablation compared with medical therapy in patients with HF. (Level of Evidence: B-R)

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)^[29]

Rhythm Control

AF catheter ablation to Maintain Sinus Rhythm

Class I
"1. AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication when a rhythm control strategy is desired. (Level of Evidence: A)"
"2. Prior to consideration of AF catheter ablation, assessment of the procedural risks and outcomes relevant to the individual patient is recommended. (Level of Evidence: C)"

Class III: Harm
"1. AF catheter ablation should not be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure. (Level of Evidence: C)"
"2. AF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation (Level of Evidence: C)"

Class IIa
"1. AF catheter ablation is reasonable for selected patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication. (Level of Evidence: A)"
"2. In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm control strategy prior to therapeutic trials of antiarrhythmic drug therapy, after weighing risks and outcomes of drug and ablation therapy. (Level of Evidence: B)"

Class IIb
"1. AF catheter ablation may be considered for symptomatic long-standing (>12 months) persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication, when a rhythm control strategy is desired. (Level of Evidence: B)"
"2. AF catheter ablation may be considered prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication for symptomatic persistent AF, when a rhythm control strategy is desired. (Level of Evidence: C)"

Sources

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation^[29]

References

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↑ ^17.0 ^17.1 Neven, K.; Schmidt, B.; Metzner, A.; Otomo, K.; Nuyens, D.; De Potter, T.; Chun, KR.; Ouyang, F.; Kuck, KH. (2010). "Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound". Circ Arrhythm Electrophysiol. 3 (3): 260–5. doi:10.1161/CIRCEP.109.922930. PMID 20504943. Unknown parameter |month= ignored (help)
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↑ Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. (2007). "HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation". Heart Rhythm. 4 (6): 816–61. PMID 17556213.
↑ Cappato, R.; Calkins, H.; Chen, SA.; Davies, W.; Iesaka, Y.; Kalman, J.; Kim, YH.; Klein, G.; Natale, A. (2009). "Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation". J Am Coll Cardiol. 53 (19): 1798–803. doi:10.1016/j.jacc.2009.02.022. PMID 19422987. Unknown parameter |month= ignored (help)
↑ Hsu, LF.; Jaïs, P.; Hocini, M.; Sanders, P.; Scavée, C.; Sacher, F.; Takahashi, Y.; Rotter, M.; Pasquie, JL. (2005). "Incidence and prevention of cardiac tamponade complicating ablation for atrial fibrillation". Pacing Clin Electrophysiol. 28 Suppl 1: S106–9. doi:10.1111/j.1540-8159.2005.00062.x. PMID 15683473. Unknown parameter |month= ignored (help)
↑ Ernst, S.; Ouyang, F.; Goya, M.; Löber, F.; Schneider, C.; Hoffmann-Riem, M.; Schwarz, S.; Hornig, K.; Müller, KM. (2003). "Total pulmonary vein occlusion as a consequence of catheter ablation for atrial fibrillation mimicking primary lung disease". J Cardiovasc Electrophysiol. 14 (4): 366–70. PMID 12741706. Unknown parameter |month= ignored (help)
↑ January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC; et al. (2019). "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons". Circulation. 140 (2): e125–e151. doi:10.1161/CIR.0000000000000665. PMID 30686041.
↑ ^29.0 ^29.1 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.

Template:WikiDoc Sources CME Category::Cardiology

[Sarabanda-2005-1] 1.0 ^1.1 ^1.2 ^1.3 Sarabanda, AV.; Bunch, TJ.; Johnson, SB.; Mahapatra, S.; Milton, MA.; Leite, LR.; Bruce, GK.; Packer, DL. (2005). "Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system". J Am Coll Cardiol. 46 (10): 1902–12. doi:10.1016/j.jacc.2005.07.046. PMID 16286179. Unknown parameter |month= ignored (help)

[pmid34020968-2] 2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 ^2.6 Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee (2021). "Atrial fibrillation: diagnosis and management-summary of NICE guidance". BMJ. 373: n1150. doi:10.1136/bmj.n1150. PMID 34020968 Check |pmid= value (help).

[3] Meininger, GR.; Calkins, H.; Lickfett, L.; Lopath, P.; Fjield, T.; Pacheco, R.; Harhen, P.; Rodriguez, ER.; Berger, R. (2003). "Initial experience with a novel focused ultrasound ablation system for ring ablation outside the pulmonary vein". J Interv Card Electrophysiol. 8 (2): 141–8. PMID 12766506. Unknown parameter |month= ignored (help)

[4] Metzner, A.; Chun, KR.; Neven, K.; Fuernkranz, A.; Ouyang, F.; Antz, M.; Tilz, R.; Zerm, T.; Koektuerk, B. (2010). "Long-term clinical outcome following pulmonary vein isolation with high-intensity focused ultrasound balloon catheters in patients with paroxysmal atrial fibrillation". Europace. 12 (2): 188–93. doi:10.1093/europace/eup416. PMID 20089752. Unknown parameter |month= ignored (help)

[5] Neven, K.; Schmidt, B.; Metzner, A.; Otomo, K.; Nuyens, D.; De Potter, T.; Chun, KR.; Ouyang, F.; Kuck, KH. (2010). "Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound". Circ Arrhythm Electrophysiol. 3 (3): 260–5. doi:10.1161/CIRCEP.109.922930. PMID 20504943. Unknown parameter |month= ignored (help)

[Metzner-2011-6] 6.0 ^6.1 ^6.2 Metzner, A.; Schmidt, B.; Fuernkranz, A.; Wissner, E.; Tilz, RR.; Chun, KR.; Neven, K.; Konstantinidou, M.; Rillig, A. (2011). "One-year clinical outcome after pulmonary vein isolation using the novel endoscopic ablation system in patients with paroxysmal atrial fibrillation". Heart Rhythm. 8 (7): 988–93. doi:10.1016/j.hrthm.2011.02.030. PMID 21354329. Unknown parameter |month= ignored (help)

[pmid16908781-7] 7.0 ^7.1 ^7.2 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL (2006). "ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (7): e257–354. doi:10.1161/CIRCULATIONAHA.106.177292. PMID 16908781. Retrieved 2013-01-07. Unknown parameter |month= ignored (help)

[pmid14557355-8] 8.0 ^8.1 ^8.2 Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E; et al. (2003). "Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation". Circulation. 108 (19): 2355–60. doi:10.1161/01.CIR.0000095796.45180.88. PMID 14557355.

[pmid15604320-9] 9.0 ^9.1 ^9.2 Jais P, Sanders P, Hsu LF, Hocini M, Haissaguerre M (2005). "Catheter ablation for atrial fibrillation". Heart. 91 (1): 7–9. doi:10.1136/hrt.2003.030205. PMC 1768634. PMID 15604320.

[urlMedscape_Log_In-10] "Medscape Log In". Retrieved 2013-01-09.

[urlMiller_Family_Heart_&_Vascular_Institute-11] "Miller Family Heart & Vascular Institute". Retrieved 2013-01-09.

[12] Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, Khunnawat C, Ngarmukos T. (2004). "A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate". J Am Coll Cardiol. 43 (11): 2044–53. doi:10.1016/j.jacc.2003.12.054. PMID 15172410.

[Schreieck-2002-13] Schreieck, J.; Zrenner, B.; Kumpmann, J.; Ndrepepa, G.; Schneider, MA.; Deisenhofer, I.; Schmitt, C. (2002). "Prospective randomized comparison of closed cooled-tip versus 8-mm-tip catheters for radiofrequency ablation of typical atrial flutter". J Cardiovasc Electrophysiol. 13 (10): 980–5. PMID 12435182. Unknown parameter |month= ignored (help)

[Friedman-2004-14] 14.0 ^14.1 Friedman, PL.; Dubuc, M.; Green, MS.; Jackman, WM.; Keane, DT.; Marinchak, RA.; Nazari, J.; Packer, DL.; Skanes, A. (2004). "Catheter cryoablation of supraventricular tachycardia: results of the multicenter prospective frosty trial". Heart Rhythm. 1 (2): 129–38. doi:10.1016/j.hrthm.2004.02.022. PMID 15851143. Unknown parameter |month= ignored (help)

[Tse-2003-15] Tse, HF.; Reek, S.; Timmermans, C.; Lee, KL.; Geller, JC.; Rodriguez, LM.; Ghaye, B.; Ayers, GM.; Crijns, HJ. (2003). "Pulmonary vein isolation using transvenous catheter cryoablation for treatment of atrial fibrillation without risk of pulmonary vein stenosis". J Am Coll Cardiol. 42 (4): 752–8. PMID 12932615. Unknown parameter |month= ignored (help)

[Metzner-2010-16] 16.0 ^16.1 Metzner, A.; Chun, KR.; Neven, K.; Fuernkranz, A.; Ouyang, F.; Antz, M.; Tilz, R.; Zerm, T.; Koektuerk, B. (2010). "Long-term clinical outcome following pulmonary vein isolation with high-intensity focused ultrasound balloon catheters in patients with paroxysmal atrial fibrillation". Europace. 12 (2): 188–93. doi:10.1093/europace/eup416. PMID 20089752. Unknown parameter |month= ignored (help)

[Neven-2010-17] 17.0 ^17.1 Neven, K.; Schmidt, B.; Metzner, A.; Otomo, K.; Nuyens, D.; De Potter, T.; Chun, KR.; Ouyang, F.; Kuck, KH. (2010). "Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound". Circ Arrhythm Electrophysiol. 3 (3): 260–5. doi:10.1161/CIRCEP.109.922930. PMID 20504943. Unknown parameter |month= ignored (help)

[Dukkipati-2010-18] 18.0 ^18.1 Dukkipati, SR.; Neuzil, P.; Skoda, J.; Petru, J.; d'Avila, A.; Doshi, SK.; Reddy, VY. (2010). "Visual balloon-guided point-by-point ablation: reliable, reproducible, and persistent pulmonary vein isolation". Circ Arrhythm Electrophysiol. 3 (3): 266–73. doi:10.1161/CIRCEP.109.933283. PMID 20504945. Unknown parameter |month= ignored (help)

[Gopinath-2011-19] 19.0 ^19.1 Gopinath, D.; Lewis, WR.; Di Biase, L.; Natale, A. (2011). "Pulmonary vein antrum isolation for atrial fibrillation on therapeutic coumadin: special considerations". J Cardiovasc Electrophysiol. 22 (2): 236–9. doi:10.1111/j.1540-8167.2010.01940.x. PMID 21044211. Unknown parameter |month= ignored (help)

[Asbach-2011-20] Asbach, S.; Biermann, J.; Bode, C.; Faber, TS. (2011). "Early Heparin Administration Reduces Risk for Left Atrial Thrombus Formation during Atrial Fibrillation Ablation Procedures". Cardiol Res Pract. 2011: 615087. doi:10.4061/2011/615087. PMID 21747989.

[Mega-2012-21] Mega, JL.; Braunwald, E.; Wiviott, SD.; Bassand, JP.; Bhatt, DL.; Bode, C.; Burton, P.; Cohen, M.; Cook-Bruns, N. (2012). "Rivaroxaban in patients with a recent acute coronary syndrome". N Engl J Med. 366 (1): 9–19. doi:10.1056/NEJMoa1112277. PMID 22077192. Unknown parameter |month= ignored (help)

[22] Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. (2005). "Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation". Circulation. 111: 1100–1105. doi:10.1161/01.CIR.0000157153.30978.67. PMID 15723973.

[23] Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. (2005). "Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation". Circulation. 111: 1100–1105. doi:10.1161/01.CIR.0000157153.30978.67. PMID 15723973.

[24] Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. (2007). "HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation". Heart Rhythm. 4 (6): 816–61. PMID 17556213.

[Cappato-2009-25] Cappato, R.; Calkins, H.; Chen, SA.; Davies, W.; Iesaka, Y.; Kalman, J.; Kim, YH.; Klein, G.; Natale, A. (2009). "Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation". J Am Coll Cardiol. 53 (19): 1798–803. doi:10.1016/j.jacc.2009.02.022. PMID 19422987. Unknown parameter |month= ignored (help)

[Hsu-2005-26] Hsu, LF.; Jaïs, P.; Hocini, M.; Sanders, P.; Scavée, C.; Sacher, F.; Takahashi, Y.; Rotter, M.; Pasquie, JL. (2005). "Incidence and prevention of cardiac tamponade complicating ablation for atrial fibrillation". Pacing Clin Electrophysiol. 28 Suppl 1: S106–9. doi:10.1111/j.1540-8159.2005.00062.x. PMID 15683473. Unknown parameter |month= ignored (help)

[Ernst-2003-27] Ernst, S.; Ouyang, F.; Goya, M.; Löber, F.; Schneider, C.; Hoffmann-Riem, M.; Schwarz, S.; Hornig, K.; Müller, KM. (2003). "Total pulmonary vein occlusion as a consequence of catheter ablation for atrial fibrillation mimicking primary lung disease". J Cardiovasc Electrophysiol. 14 (4): 366–70. PMID 12741706. Unknown parameter |month= ignored (help)

[pmid30686041-28] January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC; et al. (2019). "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons". Circulation. 140 (2): e125–e151. doi:10.1161/CIR.0000000000000665. PMID 30686041.

[JanuaryWann2014-29] 29.0 ^29.1 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.

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@@ Line 1: / Line 1: @@
 __NOTOC__
+{| class="infobox" style="float:right;"
+|-
+| [[File:Siren.gif|30px|link=Atrial fibrillation resident survival guide]]|| <br> || <br>
+| [[Atrial fibrillation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
+|}
+{| class="infobox" style="float:right;"
+|-
+| [[File:Critical_Pathways.gif|88px|link=Atrial fibrillation critical pathways]]|| <br> || <br>
+|}
+{| class="infobox" style="float:right;"
+|-
+| <small>Sinus rhythm</small> [[Image:Heart conduct sinus.gif|none|75px]]
+| <small>Atrial fibrillation</small> [[Image:Heart conduct atrialfib.gif|none|100px]]
+|}
 {{Atrial fibrillation}}
-{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}
+{{CMG}}; {{AE}} {{CZ}} {{Anahita}} {{VR}} {{Laith}}
 ==Overview==
-In patients with atrial fibrillation where rate control drugs are ineffective and it is not possible to restore sinus rhythm using [[cardioversion]], non-pharmacological alternatives are available. One of the techniques used is called radiofrequency ablation, where the bundle of cells that pace the heart in the atrioventricular node, are destroyed.
+In [[patients]] with [[atrial fibrillation]] where [[heart rate|rate]] control [[medications|drugs]] are ineffective and it is not possible to restore [[sinus rhythm]] using [[cardioversion]], non-[[pharmacology|pharmacological]] alternatives are available. One of the techniques used is called [[catheter ablation]], where the bundle of [[Cell (biology)|cells]] that pace the [[heart]] in the [[atrioventricular node]], are destroyed using [[radiofrequency]] energy source, the dominant energy source for [[catheter ablation]]. [[Cryoablation]] has more recently been developed as a tool for [[atrial fibrillation]] ([[atrial fibrillation|AF]]) [[ablation]] procedures. Other energy sources and tools are in various stages of development and/or clinical investigation. There are three classes of indications for using [[catheter ablation]] for [[atrial fibrillation]] ([[atrial fibrillation|AF]]). The cornerstone for most [[atrial fibrillation]] [[ablation]] procedures are [[ablation]] strategies that target the [[pulmonary veins]] and/or [[pulmonary vein|pulmonary vein antrum]] while electrical isolation is the goal. Due to high risk of [[thromboembolism]] in [[patients]] with [[atrial fibrillation]], careful attention and starting [[anticoagulation]] in [[atrial fibrillation]] [[patients]] before, during, and after [[ablation]] is important. Moreover, possible [[Complication (medicine)|complications]] and [[Adverse effect (medicine)|adverse effects]] associated with [[catheter ablation]] in [[atrial fibrillation]] [[patients]] should be considerd.
+==Indications for Catheter and Surgical Ablation==
+*The indications of [[ablation]] among [[patients]] with [[atrial fibrillation]] are stratified as class I, class IIa, class IIb, and class III.<ref name="Sarabanda-2005">{{Cite journal  | last1 = Sarabanda | first1 = AV. | last2 = Bunch | first2 = TJ. | last3 = Johnson | first3 = SB. | last4 = Mahapatra | first4 = S. | last5 = Milton | first5 = MA. | last6 = Leite | first6 = LR. | last7 = Bruce | first7 = GK. | last8 = Packer | first8 = DL. | title = Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system. | journal = J Am Coll Cardiol | volume = 46 | issue = 10 | pages = 1902-12 | month = Nov | year = 2005 | doi = 10.1016/j.jacc.2005.07.046 | PMID = 16286179 }}</ref>
+*One of the primary indications (class I) of [[ablation]] among [[patients]] with [[atrial fibrillation]] is the presence of [[symprtom|symptomatic]] [[atrial fibrillation]], which is refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
+*Balloon-based [[ultrasound]] [[ablation]] and [[Laser ablation|laser based ablation]] systems have also been developed for [[ablation]] of [[atrial fibrillation]] ([[AF]]).<ref>{{Cite journal  | last1 = Meininger | first1 = GR. | last2 = Calkins | first2 = H. | last3 = Lickfett | first3 = L. | last4 = Lopath | first4 = P. | last5 = Fjield | first5 = T. | last6 = Pacheco | first6 = R. | last7 = Harhen | first7 = P. | last8 = Rodriguez | first8 = ER. | last9 = Berger | first9 = R. | title = Initial experience with a novel focused ultrasound ablation system for ring ablation outside the pulmonary vein. | journal = J Interv Card Electrophysiol | volume = 8 | issue = 2 | pages = 141-8 | month = Apr | year = 2003 | doi =  | PMID = 12766506 }}</ref><ref>{{Cite journal  | last1 = Metzner | first1 = A. | last2 = Chun | first2 = KR. | last3 = Neven | first3 = K. | last4 = Fuernkranz | first4 = A. | last5 = Ouyang | first5 = F. | last6 = Antz | first6 = M. | last7 = Tilz | first7 = R. | last8 = Zerm | first8 = T. | last9 = Koektuerk | first9 = B. | title = Long-term clinical outcome following pulmonary vein isolation with high-intensity focused ultrasound balloon catheters in patients with paroxysmal atrial fibrillation. | journal = Europace | volume = 12 | issue = 2 | pages = 188-93 | month = Feb | year = 2010 | doi = 10.1093/europace/eup416 | PMID = 20089752 }}</ref><ref>{{Cite journal  | last1 = Neven | first1 = K. | last2 = Schmidt | first2 = B. | last3 = Metzner | first3 = A. | last4 = Otomo | first4 = K. | last5 = Nuyens | first5 = D. | last6 = De Potter | first6 = T. | last7 = Chun | first7 = KR. | last8 = Ouyang | first8 = F. | last9 = Kuck | first9 = KH. | title = Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound. | journal = Circ Arrhythm Electrophysiol | volume = 3 | issue = 3 | pages = 260-5 | month = Jun | year = 2010 | doi = 10.1161/CIRCEP.109.922930 | PMID = 20504943 }}</ref><ref name="Metzner-2011">{{Cite journal  | last1 = Metzner | first1 = A. | last2 = Schmidt | first2 = B. | last3 = Fuernkranz | first3 = A. | last4 = Wissner | first4 = E. | last5 = Tilz | first5 = RR. | last6 = Chun | first6 = KR. | last7 = Neven | first7 = K. | last8 = Konstantinidou | first8 = M. | last9 = Rillig | first9 = A. | title = One-year clinical outcome after pulmonary vein isolation using the novel endoscopic ablation system in patients with paroxysmal atrial fibrillation. | journal = Heart Rhythm | volume = 8 | issue = 7 | pages = 988-93 | month = Jul | year = 2011 | doi = 10.1016/j.hrthm.2011.02.030 | PMID = 21354329 }}</ref><ref name="pmid16908781">{{cite journal |author=Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL |title=ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society |journal=[[Circulation]] |volume=114 |issue=7 |pages=e257–354 |year=2006 |month=August |pmid=16908781 |doi=10.1161/CIRCULATIONAHA.106.177292 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16908781 |accessdate=2013-01-07}}</ref>
+===Class I Indications===
+In [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III]] [[antiarrhythmic medication]], [[catheter ablation]] is recommended.<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
+===Class IIa Indications===
+*In [[symptom|symptomatic]] [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[catheter ablation]] is reasonable.<ref name="Sarabanda-2005">{{Cite journal  | last1 = Sarabanda | first1 = AV. | last2 = Bunch | first2 = TJ. | last3 = Johnson | first3 = SB. | last4 = Mahapatra | first4 = S. | last5 = Milton | first5 = MA. | last6 = Leite | first6 = LR. | last7 = Bruce | first7 = GK. | last8 = Packer | first8 = DL. | title = Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system. | journal = J Am Coll Cardiol | volume = 46 | issue = 10 | pages = 1902-12 | month = Nov | year = 2005 | doi = 10.1016/j.jacc.2005.07.046 | PMID = 16286179 }}</ref>
+*In [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] [[patients]], prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with either [[Antiarrhythmic agent|class I or III antiarrhythmic agent]], [[catheter ablation]] is reasonable.
+*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]], refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[surgery|surgical]] [[ablation]] is reasonable.
+*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] [[atrial fibrillation|persistent AF]], refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[surgery|surgical ablation]] is reasonable.
+*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]], refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[surgery|surgical ablation]] is reasonable.
+*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with either [[Antiarrhythmic agent|class I or III antiarrhythmic agent]], [[surgery|surgical ablation]] is reasonable.
+*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] [[atrial fibrillation|persistent AF]] prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with either [[Antiarrhythmic agent|class I or III antiarrhythmic agent]], [[surgery|surgical ablation]] is reasonable.
+===Class IIb Indications===
+*In [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[catheter ablation]] may be considered.<ref name="Sarabanda-2005">{{Cite journal  | last1 = Sarabanda | first1 = AV. | last2 = Bunch | first2 = TJ. | last3 = Johnson | first3 = SB. | last4 = Mahapatra | first4 = S. | last5 = Milton | first5 = MA. | last6 = Leite | first6 = LR. | last7 = Bruce | first7 = GK. | last8 = Packer | first8 = DL. | title = Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system. | journal = J Am Coll Cardiol | volume = 46 | issue = 10 | pages = 1902-12 | month = Nov | year = 2005 | doi = 10.1016/j.jacc.2005.07.046 | PMID = 16286179 }}</ref>
+*In [[patients]] with [[symptom|symptomatic]] [[atrial fibrillation|persistent atrial fibrillation]] prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with a [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[catheter ablation]] may be considered.
+*In [[patients]] with [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]] prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with a [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], [[catheter ablation]] may be considered.
+*In [[patients]] who are undergoing [[surgery]] for other indications with [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]] prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with a [[Antiarrhythmic agent|class I or III antiarrhythmic agent]], [[surgery|surgical ablation]] may be considered.
+*In [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have not failed [[catheter ablation]] but prefer a [[surgery|surgical approach]].
+*In [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have failed one or more attempts at [[catheter ablation]].
+*In [[symptom|symptomatic]] [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one tion|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have not failed [[catheter ablation]] but prefer a [[surgery|surgical approach]].
+*In [[symptom|symptomatic]] [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one tion|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have failed one or more attempts at [[catheter ablation]].
+*In [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have not failed [[catheter ablation]] but prefer a [[surgery|surgical approach]].
+*In [[symptom|symptomatic]] longstanding [[atrial fibrillation|persistent atrial fibrillation]] [[patients]] who are either refractory or intolerant to at least one [[Antiarrhythmic agent|class I or III antiarrhythmic medication]], stand alone [[surgery|surgical ablation]] may be considered if they have failed one or more attempts at [[catheter ablation]].
+===Class III Indications===
+In [[symptom|symptomatic]] paroxysmal or persistent or longstanding persistent [[atrial fibrillation]] [[patients]], prior to initiation of [[Antiarrhythmic agent|antiarrhythmic drug therapy]] with a [[Antiarrhythmic agent|class I or III antiarrhythmic agent]], stand alone [[surgery|surgical ablation]] is not recommended.<ref name="Sarabanda-2005">{{Cite journal  | last1 = Sarabanda | first1 = AV. | last2 = Bunch | first2 = TJ. | last3 = Johnson | first3 = SB. | last4 = Mahapatra | first4 = S. | last5 = Milton | first5 = MA. | last6 = Leite | first6 = LR. | last7 = Bruce | first7 = GK. | last8 = Packer | first8 = DL. | title = Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system. | journal = J Am Coll Cardiol | volume = 46 | issue = 10 | pages = 1902-12 | month = Nov | year = 2005 | doi = 10.1016/j.jacc.2005.07.046 | PMID = 16286179 }}</ref>
+==Recommendations Regarding Catheter Ablation Technique==
+*The cornerstone for most [[atrial fibrillation]] [[ablation]] procedures are [[ablation]] strategies that target the [[pulmonary veins]] and/or [[pulmonary vein|pulmonary vein antrum]].<ref name="pmid14557355">{{cite journal| author=Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E | display-authors=etal| title=Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. | journal=Circulation | year= 2003 | volume= 108 | issue= 19 | pages= 2355-60 | pmid=14557355 | doi=10.1161/01.CIR.0000095796.45180.88 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14557355  }} </ref><ref name="pmid15604320">{{cite journal| author=Jais P, Sanders P, Hsu LF, Hocini M, Haissaguerre M| title=Catheter ablation for atrial fibrillation. | journal=Heart | year= 2005 | volume= 91 | issue= 1 | pages= 7-9 | pmid=15604320 | doi=10.1136/hrt.2003.030205 | pmc=1768634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15604320  }} </ref>
+*While targeting the [[pulmonary veins]], electrical isolation should be the goal.<ref name="pmid14557355">{{cite journal| author=Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E | display-authors=etal| title=Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. | journal=Circulation | year= 2003 | volume= 108 | issue= 19 | pages= 2355-60 | pmid=14557355 | doi=10.1161/01.CIR.0000095796.45180.88 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14557355  }} </ref>
+*Electrical isolation requires, at a minimum, assessment and demonstration of entrance block into the [[pulmonary vein]].<ref name="pmid14557355">{{cite journal| author=Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E | display-authors=etal| title=Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. | journal=Circulation | year= 2003 | volume= 108 | issue= 19 | pages= 2355-60 | pmid=14557355 | doi=10.1161/01.CIR.0000095796.45180.88 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14557355  }} </ref><ref name="pmid15604320">{{cite journal| author=Jais P, Sanders P, Hsu LF, Hocini M, Haissaguerre M| title=Catheter ablation for atrial fibrillation. | journal=Heart | year= 2005 | volume= 91 | issue= 1 | pages= 7-9 | pmid=15604320 | doi=10.1136/hrt.2003.030205 | pmc=1768634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15604320  }} </ref>
+*Monitoring for [[pulmonary vein]] reconduction for 20 minutes following initial [[pulmonary vein]] isolation should be considered.
+*Careful identification of the [[pulmonary vein]] ostia is mandatory to avoid [[ablation]] within the [[pulmonary veins]].
+*If a focal trigger is identified outside a [[pulmonary vein]] at the time of an [[atrial fibrillation]] [[ablation]] procedure, [[ablation]] of that focal trigger should be considered.
+*If additional linear lesions are applied, operators should consider using mapping and pacing maneuvers to assess for line completeness.
+*[[Ablation]] of the [[Tricuspid valve|cavotricuspid isthmus]] (fibrous [[Tissue (biology)|tissue]] in the lower [[right atrium]] between the [[inferior vena cava]] and the |[[tricuspid valve]]) is recommended in [[patients]] with a history of typical [[atrial flutter]] or inducible [[tricuspid valve|cavotricuspid isthmus]] dependent [[atrial flutter]].<ref name="pmid15604320">{{cite journal| author=Jais P, Sanders P, Hsu LF, Hocini M, Haissaguerre M| title=Catheter ablation for atrial fibrillation. | journal=Heart | year= 2005 | volume= 91 | issue= 1 | pages= 7-9 | pmid=15604320 | doi=10.1136/hrt.2003.030205 | pmc=1768634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15604320  }} </ref>
+*If [[patients]] with long standing persistent [[atrial fbrillation]] are approached, operators should consider more extensive [[ablation]] based on linear lesions or complex fractionated electrograms.
+*It is recommended that [[radiofrequency]] power be reduced when creating lesions along the posterior wall near the [[esophagus]].
 ==Radiofrequency Ablation==
-To control rate it is possible to destroy the bundle of cells connecting the upper and lower chambers of the heart - the [[atrioventricular node]] - which regulates heart rate, and to implant a [[artificial pacemaker|pacemaker]] instead. A more complex technique, which avoids the need for a pacemaker, involves ablating groups of cells near the pulmonary veins where atrial fibrillation is thought to originate, or creating more extensive lesions in an attempt to prevent atrial fibrillation from establishing itself.<ref name="pmid16908781"/>
+*In [[patients]] with [[symptom|symptomatic]] [[atrial fibrillation|paroxysmal atrial fibrillation]] who did not tolerate [[medications]] or when [[medications]] are not successful, [[radiofrequency ablation]] is recommended.<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
+*To control rate it is possible to destroy the bundle of [[Cell (biology)|cells]] connecting the [[heart|upper and lower chambers of the heart]] - the [[atrioventricular node]] - which regulates [[heart rate]], and to implant a [[artificial pacemaker|pacemaker]] instead.<ref name="pmid16908781">{{cite journal |author=Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL |title=ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society |journal=[[Circulation]] |volume=114 |issue=7 |pages=e257–354 |year=2006 |month=August |pmid=16908781 |doi=10.1161/CIRCULATIONAHA.106.177292 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16908781 |accessdate=2013-01-07}}</ref>
+*A more complex technique, which avoids the need for a [[Artificial pacemaker|pacemaker]], involves [[ablation|ablating]] groups of [[Cell (biology)|cells]] near the [[pulmonary veins]] where [[atrial fibrillation]] is thought to originate, or creating more extensive lesions in an attempt to prevent [[atrial fibrillation]] from establishing itself.<ref name="pmid16908781">{{cite journal |author=Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL |title=ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society |journal=[[Circulation]] |volume=114 |issue=7 |pages=e257–354 |year=2006 |month=August |pmid=16908781 |doi=10.1161/CIRCULATIONAHA.106.177292 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16908781 |accessdate=2013-01-07}}</ref>
+*[[Ablation]] is a newer technique and has shown some promise for cases of recurrent [[atrial fibrillation]] that are unresponsive to conventional [[treatments]]. [[Radiofrequency ablation]] ([[RFA]]) uses radiofrequency energy to destroy abnormal electrical pathways in [[heart]] [[Tissue (biology)|tissue]].
+*Radiofrequency energy is delivered by way of a [[vein|transvenous]] [[electrode]] [[catheter]]. The energy emitting probe ([[electrode]]) is placed into the [[heart]] through a [[catheter]] inserted into [[veins]] in the groin or [[neck]].
+*[[Electrodes]] that can detect electrical activity from inside the [[heart]] are also inserted, and the [[Electrophysiology|electrophysiologist]] uses these to map an area of the [[heart]] in order to locate the abnormal electrical activity before eliminating the responsible [[Tissue (biology)|tissue]].
+*Most [[atrial fibrillation]] [[ablations]] consist of isolating the electrical pathways from the [[pulmonary vein]]s ([[pulmonary vein|PV]]), which are located on the [[Anatomical terms of location|posterior]] wall of the [[left atrium]].  All other [[veins]] from the body (including [[neck]] and groin) lead to the [[right atrium]], so in order to get to the [[left atrium]] the [[catheters]] must get across the [[Interatrial septum|atrial septum]]. This is done by piercing a small hole in the [[Interatrial septum|septal wall]] (transseptal approach).  Once the [[catheter]] is in the [[left atrium]], the [[physician]] may perform Wide Area Circumferential [[Ablation]] (WACA) to electrically isolate the [[pulmonary veins]] from the [[left atrium]].<ref name="urlMedscape Log In">{{cite web |url=http://www.medscape.com/viewarticle/532503_2 |title=Medscape Log In |format= |work= |accessdate=2013-01-09}}</ref><ref name="urlMiller Family Heart & Vascular Institute">{{cite web |url=http://www.clevelandclinic.org/heartcenter/pub/atrial_fibrillation/pulmonaryvein_ablation.htm |title=Miller Family Heart & Vascular Institute |format= |work= |accessdate=2013-01-09}}</ref>
+*Some more recent approaches to [[ablation|ablating]] [[atrial fibrillation]] is to target sites that are particularly disorganized in both [[atrium|atria]] as well as in the [[coronary sinus]] ([[coronary sinus|CS]]). The aforementioned sites are termed Complex Fractionated Atrial Electrogram (CFAE) sites.<ref>{{cite journal | author= Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, Khunnawat C, Ngarmukos T. | title=A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate | journal=J Am Coll Cardiol | year=2004 | pages=2044–53 | volume=43 | issue=11 | pmid= 15172410 | doi= 10.1016/j.jacc.2003.12.054}}</ref>
+*It is believed by some that the CFAE sites are the cause of [[atrial fibrillation]], or a combination of the [[pulmonary veins]] and CFAE sites are to blame.
+*Most [[Tissue (biology)|tissues]] exposed to temperatures of 50 C or higher for more than several seconds will show irreversible [[coagulation necrosis]], and evolve into non-conducting myocardial scar.
+*The following factors promote the formation of larger lesions and improve procedure efficacy:
+**High power delivery
+**Good [[electrode]]–[[Tissue (biology)|tissue]] contact
+**Adequate [[ablation]] duration
+*Significant [[Complication (medicine)|complications]] can occur during [[atrial fibrillation]] [[ablation]] if high radiofrequency power is administered in an uncontrolled fashion.
+*The increased risk of [[atrial fibrillation]] [[ablation]] compared to [[ablation]] of other [[Cardiac arrhythmia|arrhythmias]] may be attributed to the great surface area of [[Tissue (biology)|tissue]] [[ablation|ablated]], the large cumulative energy delivery, the risk of systemic [[thromboembolism]], and the close location of structures susceptible to collateral [[injury]], such as [[phrenic nerve]], [[pulmonary veins]], and [[esophagus]].
+*[[Thrombus]], char formation and intramural steam pops can also occur.
+*[[Radiofrequency ablation|Conventional radiofrequency]] [[electrodes]] were employed earlier. But comparative trials against conventional radiofrequency [[electrodes]] have demonstrated that irrigated tip and large tip radiofrequency technologies have increased efficacy and decreased procedure duration.<ref name="Schreieck-2002">{{Cite journal  | last1 = Schreieck | first1 = J. | last2 = Zrenner | first2 = B. | last3 = Kumpmann | first3 = J. | last4 = Ndrepepa | first4 = G. | last5 = Schneider | first5 = MA. | last6 = Deisenhofer | first6 = I. | last7 = Schmitt | first7 = C. | title = Prospective randomized comparison of closed cooled-tip versus 8-mm-tip catheters for radiofrequency ablation of typical atrial flutter. | journal = J Cardiovasc Electrophysiol | volume = 13 | issue = 10 | pages = 980-5 | month = Oct | year = 2002 | doi =  | PMID = 12435182 }}</ref>
+==Cryoablation==
+*[[Cryoablation]] is recommended when [[radiofrequency ablation|point by point radiofrequency ablation]] is not proper in [[atrial fibrillation]] [[patients]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
+*[[Cryoablation]] is a new technique which uses cryothermal energy as an alternative energy source. In [[cryoablation]], [[Tissue (biology)|tissue]] freezing coolant, liquid [[nitrous oxide]] is delivered under [[pressure]] through a [[catheter]] where it changes to [[gas]], resulting in cooling of surrounding [[Tissue (biology)|tissue]]. [[Tissue (biology)|Tissue]] [[injury]] results from [[Tissue (biology)|tissue]] freezing with a creation of ice crystals within the [[Cell (biology)|cell]] that disrupts [[Cell (biology)|cell]] membranes and interrupts both [[Cell (biology)|cellular]] metabolism and any electrical activity in that [[Cell (biology)|cell]]. Interruption of microvascular [[perfusion]] also produces [[Cell (biology)|cell]] death by interrupting [[blood]] flow.<ref name="Friedman-2004">{{Cite journal  | last1 = Friedman | first1 = PL. | last2 = Dubuc | first2 = M. | last3 = Green | first3 = MS. | last4 = Jackman | first4 = WM. | last5 = Keane | first5 = DT. | last6 = Marinchak | first6 = RA. | last7 = Nazari | first7 = J. | last8 = Packer | first8 = DL. | last9 = Skanes | first9 = A. | title = Catheter cryoablation of supraventricular tachycardia: results of the multicenter prospective frosty trial. | journal = Heart Rhythm | volume = 1 | issue = 2 | pages = 129-38 | month = Jul | year = 2004 | doi = 10.1016/j.hrthm.2004.02.022 | PMID = 15851143 }}</ref>
+*More recently, a number of point-by-point and balloon-based [[cryoablation]] systems have been developed.<ref name="Friedman-2004">{{Cite journal  | last1 = Friedman | first1 = PL. | last2 = Dubuc | first2 = M. | last3 = Green | first3 = MS. | last4 = Jackman | first4 = WM. | last5 = Keane | first5 = DT. | last6 = Marinchak | first6 = RA. | last7 = Nazari | first7 = J. | last8 = Packer | first8 = DL. | last9 = Skanes | first9 = A. | title = Catheter cryoablation of supraventricular tachycardia: results of the multicenter prospective frosty trial. | journal = Heart Rhythm | volume = 1 | issue = 2 | pages = 129-38 | month = Jul | year = 2004 | doi = 10.1016/j.hrthm.2004.02.022 | PMID = 15851143 }}</ref><ref name="Tse-2003">{{Cite journal  | last1 = Tse | first1 = HF. | last2 = Reek | first2 = S. | last3 = Timmermans | first3 = C. | last4 = Lee | first4 = KL. | last5 = Geller | first5 = JC. | last6 = Rodriguez | first6 = LM. | last7 = Ghaye | first7 = B. | last8 = Ayers | first8 = GM. | last9 = Crijns | first9 = HJ. | title = Pulmonary vein isolation using transvenous catheter cryoablation for treatment of atrial fibrillation without risk of pulmonary vein stenosis. | journal = J Am Coll Cardiol | volume = 42 | issue = 4 | pages = 752-8 | month = Aug | year = 2003 | doi =  | PMID = 12932615 }}</ref>
+*Point-by-point [[cryoablation]] approach is proved to be associated with low [[Complication (medicine)|complication]] rate, but the procedure is lengthy, and the long-term efficacy is limited. This ultimately paved way for the development of a [[cryoablation]] balloon [[ablation]] [[catheter]].
+*Regional [[blood flow]] around the tip of the [[catheter]] or balloon influences the achievement of optimal [[cryoablation]]. Continuous [[blood flow]] reduces the chance of achieving a full-thickness [[cryoablation]]. Because of this, complete [[vein]] occlusion is required during the procedure.
-[[Ablation]] is a newer technique and has shown some promise for cases of recurrent AF that are unresponsive to conventional treatments. [[Radiofrequency ablation]] (RFA) uses radiofrequency energy to destroy abnormal electrical pathways in heart tissue. The energy emitting probe ([[electrode]]) is placed into the heart through a [[catheter]] inserted into veins in the groin or neck.  Electrodes that can detect electrical activity from inside the heart are also inserted, and the electrophysiologist uses these to "map" an area of the heart in order to locate the abnormal electrical activity before eliminating the responsible tissue.
+==Ultrasound Ablation==
+*Although [[radiofrequency ablation]] and [[cryoablation]] are the two standard [[ablation]] systems used for [[catheter]] [[ablation]] of [[atrial fibrillation]] today, balloon-based [[ultrasound]] [[ablation]] have also been developed for [[atrial fibrillation]] [[ablation]].<ref name="Metzner-2010">{{Cite journal  | last1 = Metzner | first1 = A. | last2 = Chun | first2 = KR. | last3 = Neven | first3 = K. | last4 = Fuernkranz | first4 = A. | last5 = Ouyang | first5 = F. | last6 = Antz | first6 = M. | last7 = Tilz | first7 = R. | last8 = Zerm | first8 = T. | last9 = Koektuerk | first9 = B. | title = Long-term clinical outcome following pulmonary vein isolation with high-intensity focused ultrasound balloon catheters in patients with paroxysmal atrial fibrillation. | journal = Europace | volume = 12 | issue = 2 | pages = 188-93 | month = Feb | year = 2010 | doi = 10.1093/europace/eup416 | PMID = 20089752 }}</ref><ref name="Neven-2010">{{Cite journal  | last1 = Neven | first1 = K. | last2 = Schmidt | first2 = B. | last3 = Metzner | first3 = A. | last4 = Otomo | first4 = K. | last5 = Nuyens | first5 = D. | last6 = De Potter | first6 = T. | last7 = Chun | first7 = KR. | last8 = Ouyang | first8 = F. | last9 = Kuck | first9 = KH. | title = Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound. | journal = Circ Arrhythm Electrophysiol | volume = 3 | issue = 3 | pages = 260-5 | month = Jun | year = 2010 | doi = 10.1161/CIRCEP.109.922930 | PMID = 20504943 }}</ref>
+*The first of the balloon [[ablation]] systems to be approved for clinical use is the focused [[ultrasound]] [[ablation]] system that uses [[high intensity focused ultrasound]] ([[high intensity focused ultrasound|HIFU]]).<ref name="Metzner-2010">{{Cite journal  | last1 = Metzner | first1 = A. | last2 = Chun | first2 = KR. | last3 = Neven | first3 = K. | last4 = Fuernkranz | first4 = A. | last5 = Ouyang | first5 = F. | last6 = Antz | first6 = M. | last7 = Tilz | first7 = R. | last8 = Zerm | first8 = T. | last9 = Koektuerk | first9 = B. | title = Long-term clinical outcome following pulmonary vein isolation with high-intensity focused ultrasound balloon catheters in patients with paroxysmal atrial fibrillation. | journal = Europace | volume = 12 | issue = 2 | pages = 188-93 | month = Feb | year = 2010 | doi = 10.1093/europace/eup416 | PMID = 20089752 }}</ref><ref name="Neven-2010">{{Cite journal  | last1 = Neven | first1 = K. | last2 = Schmidt | first2 = B. | last3 = Metzner | first3 = A. | last4 = Otomo | first4 = K. | last5 = Nuyens | first5 = D. | last6 = De Potter | first6 = T. | last7 = Chun | first7 = KR. | last8 = Ouyang | first8 = F. | last9 = Kuck | first9 = KH. | title = Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound. | journal = Circ Arrhythm Electrophysiol | volume = 3 | issue = 3 | pages = 260-5 | month = Jun | year = 2010 | doi = 10.1161/CIRCEP.109.922930 | PMID = 20504943 }}</ref>
-Most AF ablations consist of isolating the electrical pathways from the [[pulmonary vein]]s (PV)<ref>[http://www.clevelandclinic.org/heartcenter/pub/atrial_fibrillation/pulmonaryvein_ablation.htm The Cleveland Clinic]</ref>, which are located on the posterior wall of the left atrium. All other veins from the body (including neck and groin) lead to the right atrium, so in order to get to the left atrium the catheters must get across the atrial septum. This is done by piercing a small hole in the septal wall. This is called a transseptal approach. Once in the left atrium, the physician may perform ''Wide Area Circumferential Ablation'' (WACA) to electrically isolate the PVs from the left atrium.<ref>[http://www.medscape.com/viewarticle/532503_2 Medscape] </ref>
+==Laser Ablation==
+*[[Laser]] balloon [[ablation]] could be considered when [[radiofrequency ablation]] is not effective or tolerated.<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
+*Balloon based [[laser ablation]] system involving a compliant balloon [[ablation]] [[catheter]] are being developed through which arcs of [[laser]] energy are delivered under visual guidance.<ref name="Dukkipati-2010">{{Cite journal  | last1 = Dukkipati | first1 = SR. | last2 = Neuzil | first2 = P. | last3 = Skoda | first3 = J. | last4 = Petru | first4 = J. | last5 = d'Avila | first5 = A. | last6 = Doshi | first6 = SK. | last7 = Reddy | first7 = VY. | title = Visual balloon-guided point-by-point ablation: reliable, reproducible, and persistent pulmonary vein isolation. | journal = Circ Arrhythm Electrophysiol | volume = 3 | issue = 3 | pages = 266-73 | month = Jun | year = 2010 | doi = 10.1161/CIRCEP.109.933283 | PMID = 20504945 }}</ref><ref name="Metzner-2011">{{Cite journal  | last1 = Metzner | first1 = A. | last2 = Schmidt | first2 = B. | last3 = Fuernkranz | first3 = A. | last4 = Wissner | first4 = E. | last5 = Tilz | first5 = RR. | last6 = Chun | first6 = KR. | last7 = Neven | first7 = K. | last8 = Konstantinidou | first8 = M. | last9 = Rillig | first9 = A. | title = One-year clinical outcome after pulmonary vein isolation using the novel endoscopic ablation system in patients with paroxysmal atrial fibrillation. | journal = Heart Rhythm | volume = 8 | issue = 7 | pages = 988-93 | month = Jul | year = 2011 | doi = 10.1016/j.hrthm.2011.02.030 | PMID = 21354329 }}</ref>
+*Small [[clinical trials]] have demonstrated the safety and effectiveness of this [[ablation]] system, which is now approved for use in Europe and is entering a pivotal randomized [[clinical trial]] in the United States.<ref name="Dukkipati-2010">{{Cite journal  | last1 = Dukkipati | first1 = SR. | last2 = Neuzil | first2 = P. | last3 = Skoda | first3 = J. | last4 = Petru | first4 = J. | last5 = d'Avila | first5 = A. | last6 = Doshi | first6 = SK. | last7 = Reddy | first7 = VY. | title = Visual balloon-guided point-by-point ablation: reliable, reproducible, and persistent pulmonary vein isolation. | journal = Circ Arrhythm Electrophysiol | volume = 3 | issue = 3 | pages = 266-73 | month = Jun | year = 2010 | doi = 10.1161/CIRCEP.109.933283 | PMID = 20504945 }}</ref><ref name="Metzner-2011">{{Cite journal  | last1 = Metzner | first1 = A. | last2 = Schmidt | first2 = B. | last3 = Fuernkranz | first3 = A. | last4 = Wissner | first4 = E. | last5 = Tilz | first5 = RR. | last6 = Chun | first6 = KR. | last7 = Neven | first7 = K. | last8 = Konstantinidou | first8 = M. | last9 = Rillig | first9 = A. | title = One-year clinical outcome after pulmonary vein isolation using the novel endoscopic ablation system in patients with paroxysmal atrial fibrillation. | journal = Heart Rhythm | volume = 8 | issue = 7 | pages = 988-93 | month = Jul | year = 2011 | doi = 10.1016/j.hrthm.2011.02.030 | PMID = 21354329 }}</ref>
-Some more recent approaches to ablating AF is to target sites that are particularly disorganized in both atria as well as in the [[coronary sinus]] (CS). These sites are termed ''complex fractionated atrial electrogram'' (CFAE) sites.<ref>{{cite journal | author= Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, Khunnawat C, Ngarmukos T. | title=A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate | journal=J Am Coll Cardiol | year=2004 | pages=2044–53 | volume=43 | issue=11 | pmid= 15172410 | doi= 10.1016/j.jacc.2003.12.054}}</ref>. It is believed by some that the CFAE sites are the cause of AF, or a combination of the PVs and CFAE sites are to blame. New techniques include the use of [[cryoablation]] (tissue freezing using a coolant which flows through the catheter), microwave ablation, where tissue is ablated by the microwave energy "cooking" the adjacent tissue, and high intensity focused ultrasound (HIFU), which destroys tissue by heating. This is an area of active research, especially with respect to the RF ablation technique and emphasis on isolating the pulmonary veins that enter into the left atrium.
+==Anticoagulation Strategies==
+[[Atrial fibrillation]] [[patients]] are at increased risk of [[thromboembolism]] during, immediately following, and for several weeks to months after their [[ablation]]. Thus careful attention and starting [[anticoagulation]] in [[atrial fibrillation]] [[patients]] before, during, and after [[ablation]] for [[atrial fibrillation]] is important to avoid the occurrence of a [[thromboembolism|thromboembolic events]].
-Efficacy and risks of catheter ablation of atrial fibrillation are areas of active debate.  A worldwide survey of the outcomes of 8745 ablation procedures<ref>{{cite journal | author=Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. | title=Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation | journal=Circulation | year=2005 | volume=111 | pages=1100–1105| pmid=15723973 | doi=10.1161/01.CIR.0000157153.30978.67}}</ref> demonstrated a 52% success rate (ranging from 14.5% to 76.5% among centers), with an additional 23.9% of patients becoming asymptomatic with addition of an antiarrhythmic medication.  In 27.3% of patients, more than one procedure was required to attain these results.  There was at least one major complication in 6% of patients.  A thorough discussion of results of catheter ablation was published in 2007<ref>{{cite journal | author=Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. | title=HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation | journal=Heart Rhythm | year=2007 | volume=4 | issue=6 | pages= 816–61 | pmid=17556213}}</ref>; it notes that results are widely variable, due in part to differences in technique, follow-up, definitions of success, use of antiarrhythmic therapy, and in experience and technical proficiency.
+===Pre Ablation===
+*In [[patients]] who have [[atrial fibrillation]] for 48 hours or longer or for an unknown duration, three weeks of systemic [[anticoagulants]] at a [[therapy|therapeutic level]] prior to the procedure is required.<ref name="Gopinath-2011">{{Cite journal  | last1 = Gopinath | first1 = D. | last2 = Lewis | first2 = WR. | last3 = Di Biase | first3 = L. | last4 = Natale | first4 = A. | title = Pulmonary vein antrum isolation for atrial fibrillation on therapeutic coumadin: special considerations. | journal = J Cardiovasc Electrophysiol | volume = 22 | issue = 2 | pages = 236-9 | month = Feb | year = 2011 | doi = 10.1111/j.1540-8167.2010.01940.x | PMID = 21044211 }}</ref>
+*Prior to the [[ablation]] procedure a [[transesophageal echocardiography (TEE)|transesophageal echocardiography]] ([[TEE]]) should be performed in them.
+*[[transesophageal echocardiography (TEE)|Transesophageal echocardiography]] ([[TEE]]) in [[atrial fibrillation]] [[patients]] who have [[sinus rhythm]] at the time of [[ablation]] or [[patients]] with current [[atrial fibrillation]] who also had [[atrial fibrillaton]] for 48 hours or less prior to [[atrial fibrillation]] [[ablation]] may be considered, but it is not mandatory.
+*A [[left atrium|left atrial]] [[thrombus]] found during [[transesophageal echocardiography (TEE)|transesophageal echocardiography]] ([[TEE]]) is a [[contraindication]] for [[catheter]] [[ablation]] of [[atrial fibrillation]].
+*[[Catheter]] [[ablation]] of [[trial fibrillation]] on a [[patient]] who is [[therapy|therapeutically]] [[anticoagulant|anticoagulated]] with [[warfarin]] should also be considered.<ref name="Gopinath-2011">{{Cite journal  | last1 = Gopinath | first1 = D. | last2 = Lewis | first2 = WR. | last3 = Di Biase | first3 = L. | last4 = Natale | first4 = A. | title = Pulmonary vein antrum isolation for atrial fibrillation on therapeutic coumadin: special considerations. | journal = J Cardiovasc Electrophysiol | volume = 22 | issue = 2 | pages = 236-9 | month = Feb | year = 2011 | doi = 10.1111/j.1540-8167.2010.01940.x | PMID = 21044211 }}</ref>
-==Related Chapters==
+===During Ablation===
-* [[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation | The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
+*[[Heparin]] should be administered prior to or immediately following transseptal puncture during [[atrial fibrillation]] [[ablation]] procedures.<ref name="Asbach-2011">{{Cite journal  | last1 = Asbach | first1 = S. | last2 = Biermann | first2 = J. | last3 = Bode | first3 = C. | last4 = Faber | first4 = TS. | title = Early Heparin Administration Reduces Risk for Left Atrial Thrombus Formation during Atrial Fibrillation Ablation Procedures. | journal = Cardiol Res Pract | volume = 2011 | issue =  | pages = 615087 | month =  | year = 2011 | doi = 10.4061/2011/615087 | PMID = 21747989 }}</ref>
+*[[Atrial fibrillation]] [[ablation]] in a [[patient]] who is systemically [[anticoagulant|anticoagulated]] with [[warfarin]] does not alter the need for [[Intravenous therapy|intravenous]] [[heparin]] to maintain a [[therapy|therapeutic]] [[activated clotting time]] (300 to 400 seconds) during the procedure.
+*Administration of [[protamine]] following [[ablation]] to reverse [[heparin]] should be considered.
+===Post Ablation===
+*In [[patients]] who are not [[therapy|therapeutically]] [[anticoagulant|anticoagulated]] with [[warfarin]] at the time of [[atrial fibrillation]] [[ablation]], [[low molecular weight heparin]] or [[Intravenous therapy|intravenous]] [[heparin]] should be used to resume the systemic [[anticoagulant|anticoagulation]] with [[warfarin]] following [[atrial fibrillation]] [[ablation]].
+*Initiation of a [[Direct thrombin inhibitor|direct thrombin]] or [[Direct Xa inhibitor|factor Xa inhibitor]] after [[ablation]] may be considered as an alternative post procedure [[anticoagulant|anticoagulation strategy]].<ref name="Mega-2012">{{Cite journal  | last1 = Mega | first1 = JL. | last2 = Braunwald | first2 = E. | last3 = Wiviott | first3 = SD. | last4 = Bassand | first4 = JP. | last5 = Bhatt | first5 = DL. | last6 = Bode | first6 = C. | last7 = Burton | first7 = P. | last8 = Cohen | first8 = M. | last9 = Cook-Bruns | first9 = N. | title = Rivaroxaban in patients with a recent acute coronary syndrome. | journal = N Engl J Med | volume = 366 | issue = 1 | pages = 9-19 | month = Jan | year = 2012 | doi = 10.1056/NEJMoa1112277 | PMID = 22077192 }}</ref>
+*A reduction in the dose of [[low molecular weight heparin]] (0.5 mg/kg) should be considered because of the increased risk of post procedure [[bleeding]] following a full [[dose]] (1 mg/kg bid).
+*[[anticoagulant|Systemic anticoagulation]] with [[warfarin]] or a [[Direct thrombin inhibitor|direct thrombin]] or [[Direct Xa inhibitor|factor Xa inhibitor]] is recommended for at least two months following an [[atrial fibrillation]] [[ablation]] procedure. But decisions regarding the continuation of [[anticoagulant|systemic anticoagulation]] for more than two months following [[ablation]] should be based on the [[patients]] [[risk factors]] for [[stroke]].
+*Discontinuation of [[anticoagulant|systemic anticoagulation]] [[therapy]] post [[ablation]] is not recommended in [[patients]] who are at high risk of [[stroke]].
+*[[Patients]] in whom discontinuation of [[anticoagulant|systemic anticoagulation]] is being considered should consider undergoing continuous [[The electrocardiogram|ECG monitoring]] to screen for [[symptom|asymptomatic]] [[atrial fibrillation]].
+==Outcomes and Efficacy of Catheter Ablation==
+*Efficacy and risks of [[catheter]] [[ablation]] of [[atrial fibrillation]] are areas of active debate.<ref>{{cite journal | author=Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. | title=Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation | journal=Circulation | year=2005 | volume=111 | pages=1100–1105| pmid=15723973 | doi=10.1161/01.CIR.0000157153.30978.67}}</ref>
+*A worldwide survey of the outcomes of 8745 [[ablation]] procedures demonstrated a 52% success rate (ranging from 14.5% to 76.5% among centers), with an additional 23.9% of [[patients]] becoming [[symptom|asymptomatic]] with addition of an [[Antiarrhythmic agent|antiarrhythmic medication]].<ref>{{cite journal | author=Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. | title=Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation | journal=Circulation | year=2005 | volume=111 | pages=1100–1105| pmid=15723973 | doi=10.1161/01.CIR.0000157153.30978.67}}</ref>
+**In 27.3% of [[patients]], more than one procedure was required to attain these results.
+**There was at least one major [[complication]] in 6% of [[patients]].
+*A thorough discussion of results of [[catheter]] [[ablation]] was published in 2007. <ref>{{cite journal | author=Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. | title=HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation | journal=Heart Rhythm | year=2007 | volume=4 | issue=6 | pages= 816–61 | pmid=17556213}}</ref>
+**It notes that results are widely variable, due in part to differences in technique, follow-up, definitions of success, use of [[Antiarrhythmic agent|antiarrhythmic therapy]], and in experience and technical proficiency.
+==Prevention of Recurrence After Ablation==
+*NICE guideline updated in 2021 recommends to use [[antiarrhythmic agents]] in order to prevent [[atrial fibrillation]] recurrence after [[ablation]].<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
+*It is important to consider [[patient]]'s preference and [[Adverse effect (medicine)|side effects]] before starting [[antiarrhythmic agents]].
+*3 months after starting [[antiarrhythmic agents]] to prevent [[atrial fibrillation]] recurrence, [[patients]] should be evaluated and necessicity for continuing [[antiarrhythmic agents]] should be assessed again.<ref name="pmid34020968">{{cite journal| author=Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S, Guideline Committee| title=Atrial fibrillation: diagnosis and management-summary of NICE guidance. | journal=BMJ | year= 2021 | volume= 373 | issue=  | pages= n1150 | pmid=34020968 | doi=10.1136/bmj.n1150 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34020968  }} </ref>
+==Complications of Catheter Ablation==
+[[Catheter ablation]] of [[atrial fibrillation]] ([[AF]]) is one of the most complex interventional electrophysiologic procedures. Therefore the risk associated with [[atrial fibrillation]] ([[AF]]) [[ablation]] is higher. The following are [[Complication (medicine)|complications]] associated with [[catheter ablation]] of [[atrial fibrillation]] ([[AF]]).<ref name="Cappato-2009">{{Cite journal  | last1 = Cappato | first1 = R. | last2 = Calkins | first2 = H. | last3 = Chen | first3 = SA. | last4 = Davies | first4 = W. | last5 = Iesaka | first5 = Y. | last6 = Kalman | first6 = J. | last7 = Kim | first7 = YH. | last8 = Klein | first8 = G. | last9 = Natale | first9 = A. | title = Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. | journal = J Am Coll Cardiol | volume = 53 | issue = 19 | pages = 1798-803 | month = May | year = 2009 | doi = 10.1016/j.jacc.2009.02.022 | PMID = 19422987 }}</ref><ref name="Hsu-2005">{{Cite journal  | last1 = Hsu | first1 = LF. | last2 = Jaïs | first2 = P. | last3 = Hocini | first3 = M. | last4 = Sanders | first4 = P. | last5 = Scavée | first5 = C. | last6 = Sacher | first6 = F. | last7 = Takahashi | first7 = Y. | last8 = Rotter | first8 = M. | last9 = Pasquie | first9 = JL. | title = Incidence and prevention of cardiac tamponade complicating ablation for atrial fibrillation. | journal = Pacing Clin Electrophysiol | volume = 28 Suppl 1 | issue =  | pages = S106-9 | month = Jan | year = 2005 | doi = 10.1111/j.1540-8159.2005.00062.x | PMID = 15683473 }}</ref><ref name="Ernst-2003">{{Cite journal  | last1 = Ernst | first1 = S. | last2 = Ouyang | first2 = F. | last3 = Goya | first3 = M. | last4 = Löber | first4 = F. | last5 = Schneider | first5 = C. | last6 = Hoffmann-Riem | first6 = M. | last7 = Schwarz | first7 = S. | last8 = Hornig | first8 = K. | last9 = Müller | first9 = KM. | title = Total pulmonary vein occlusion as a consequence of catheter ablation for atrial fibrillation mimicking primary lung disease. | journal = J Cardiovasc Electrophysiol | volume = 14 | issue = 4 | pages = 366-70 | month = Apr | year = 2003 | doi =  | PMID = 12741706 }}</ref>
+*[[atrium|Atrio]]-[[Esophagus|esophageal]] [[fistula]] and [[Esophagus|esophageal]] [[injury]]
+*[[Bleeding]]
+*[[heart|Cardiac]] perforation
+*[[Cardiac tamponade]]
+*Deep [[sternum|sternal]] [[wound]] [[infection]]/[[mediastinitis]] following [[heart|cardiac]] [[surgery]]
+*[[Stomach|Gastric]] motility/[[Stomach|pyloric]] [[spasm]] disorders
+*[[Myocardial infarction]]
+*[[Pericarditis]]
+*[[Phrenic nerve paralysis]]
+*[[Pulmonary vein stenosis]]
+*Silent [[cerebral embolism]]
+*[[Stroke]] or [[Transient ischemic attack]] ([[Transient ischemic attack|TIA]]) post [[ablation]]
+*Unanticipated [[Adverse effect (medicine)|adverse device effect]]
+*[[Vagus nerve|Vagal nerve]] [[injury]]
+*Vascular access [[Complication (medicine)|complications]] like [[hematoma]], [[AV fistula]] and [[pseudoaneurysm]]
+== 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society<ref name="pmid30686041">{{cite journal| author=January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC | display-authors=etal| title=2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. | journal=Circulation | year= 2019 | volume= 140 | issue= 2 | pages= e125-e151 | pmid=30686041 | doi=10.1161/CIR.0000000000000665 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30686041  }}</ref> ==
+=== Recommendation for Catheter Ablation in HF Referenced studies that support the new recommendation are summarized in Online Data Supplement 7 ===
+{| class="wikitable" style="width: 80%;"
+|-
+| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
+|-
+| bgcolor="LemonChiffon" |1.   AF catheter ablation may be reasonable in selected patients with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF.S6.3.4-1,S6.3.4-2NEW: New evidence, including data on improved mortality rate, has been published for AF catheter ablation compared with medical therapy in patients with HF. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
+|}
+==2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>==
+===Rhythm Control===
+====AF catheter ablation to Maintain Sinus Rhythm====
+{|class="wikitable" style="width: 80%;"
+|-
+| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[AF]] [[catheter ablation]] is useful for symptomatic paroxysmal AF refractory or intolerant to at least 1 class I or III [[antiarrhythmic|antiarrhythmic medication]] when a rhythm control strategy is desired. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+|bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Prior to consideration of [[AF]] [[catheter ablation]], assessment of the procedural risks and outcomes relevant to the individual patient is recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|}
+{|class="wikitable" style="width: 80%;"
+|-
+|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III: Harm]]
+|-
+|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[AF]] [[catheter ablation]] should not be performed in patients who cannot be treated with anticoagulant therapy during and following the procedure. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|-
+|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' [[AF]] [[catheter ablation]] to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|}
+{|class="wikitable" style="width: 80%;"
+|-
+| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[AF]] [[catheter ablation]] is reasonable for selected patients with symptomatic persistent AF refractory or intolerant to at least 1 class I or III antiarrhythmic medication. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients with recurrent symptomatic paroxysmal AF, catheter ablation is a reasonable initial rhythm control strategy prior to therapeutic trials of antiarrhythmic drug therapy, after weighing risks and outcomes of drug and ablation therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|}
+{|class="wikitable" style="width: 80%;"
+|-
+| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[AF]] [[catheter ablation]] may be considered for symptomatic long-standing (>12 months) persistent [[AF]] refractory or intolerant to at least 1 class I or III [[antiarrhythmic|antiarrhythmic medication]], when a rhythm control strategy is desired. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|-
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[AF]] [[catheter ablation]] may be considered prior to initiation of [[antiarrhythmic|antiarrhythmic drug therapy]] with a class I or III [[antiarrhythmic|antiarrhythmic medication]] for symptomatic persistent [[AF]], when a rhythm control strategy is desired. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|}
 ==Sources==
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-*[http://circ.ahajournals.org/content/123/10/e269.full.pdf 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>
-*[http://circ.ahajournals.org/content/117/8/1101.full.pdf ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter] <ref name="pmid18283199">Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18283199 ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society.] ''Circulation'' 117 (8):1101-20. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.187192 DOI:10.1161/CIRCULATIONAHA.107.187192] PMID: [http://pubmed.gov/18283199 18283199]</ref>
+* [http://circ.ahajournals.org/content/early/2014/03/27/CIR.0000000000000041 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation]<ref name="JanuaryWann2014">{{cite journal|last1=January|first1=C. T.|last2=Wann|first2=L. S.|last3=Alpert|first3=J. S.|last4=Calkins|first4=H.|last5=Cleveland|first5=J. C.|last6=Cigarroa|first6=J. E.|last7=Conti|first7=J. B.|last8=Ellinor|first8=P. T.|last9=Ezekowitz|first9=M. D.|last10=Field|first10=M. E.|last11=Murray|first11=K. T.|last12=Sacco|first12=R. L.|last13=Stevenson|first13=W. G.|last14=Tchou|first14=P. J.|last15=Tracy|first15=C. M.|last16=Yancy|first16=C. W.|title=2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000041}}</ref>
 ==References==
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