Physician's Weekly Article - The New Consensus on Catheter and Surgical Ablation of AF

       Several heart rhythm organizations have collaborated to develop the first consensus statement regarding use of catheter and surgical ablation in the treatment of atrial fibrillation.

      The first transatlantic collaboration of arrhythmia organizations recently produced a consensus statement for the use of catheter and surgical ablation in the treatment of atrial fibrillation (AF). The consensus statement was developed by the Heart Rhythm Society, the European Heart Rhythm Association, and the European Cardiac Arrhythmia Society, in collaboration with the American College of Cardiology, the American Heart Association, and the Society of Thoracic Surgeons.

      "AF is an enormous and common problem that affects about 3 million Americans," says Hugh Calkins, MD, FACC, FAHA, who co-chaired a task force that developed recommendations for using ablation procedures for AF. "The main goal of the consensus statement was to provide a state-of-the-art review of the field of catheter and surgical ablation of AF. We also wanted to better define indications, techniques, and outcomes of these procedures. Over 200,000 new patients develop AF each year and the current treatment options are limited. Anti-arrhythmic drug therapy is a common treatment, but these agents are typically effective in just 40% to 60% of patients. As a result, many patients will still not have their AF adequately controlled."

      Over the past few years, catheter ablation of AF has evolved rapidly and is now a commonly performed procedure for AF. Surgical ablation is also performed, but the procedure is not as common because of its invasiveness. “The consensus statement that our task force created provides recommendations regarding ablation techniques, procedural end points, anticoagulation strategies, physician training, and patient follow up,” Dr. Calkins adds. “The hope with the new consensus statement is that we will offer a solid foundation for those involved in treating AF with ablation procedures and improve patient care”

      Honing in on Appropriate Indications

      The primary indication for catheter ablation, according to the new consensus, is to treat symptomatic AF that has been refractory or intolerant to Class 1 or Class 3 antiarrhythmic medications (Table 1). “Catheter ablation should be performed in patients who have AF, who experience symptoms from their AF, and who have failed one or more attempts to control their AF with antiarrhythmic medications,” explains Dr. Calkins. “In rare situations, it may be appropriate to perform this procedure as first-line therapy. Patients who have heart failure and/or a reduced ejection fraction may also be appropriate candidates for the procedure.”

      Surgical ablation is indicated primarily for patients with symptomatic AF who are undergoing other cardiac surgery. “Selected asymptomatic patients undergoing cardiac surgery who can undergo ablation with minimal risk may also be considered for the procedure,” Dr. Calkins says, “depending on the experience of the center. Patients who have AF and prefer a surgical approach, patients who have failed one or more attempts at catheter ablation, and patients who are not candidates for catheter ablation—such as those who can’t tolerate systemic anticoagulation for at least several months—are also good candidates for surgical ablation. In addition, a mass or a thrombus in the left atrium is a contraindication for catheter ablation, but surgical ablation may still be performed because it can be done under direct visualization.”

      An important statement in the task force’s consensus was the notion that electrical isolation of the pulmonary veins is the cornerstone for most AF procedures. “Although the procedure itself may be performed slightly differently in each hospital, we have concluded that for most patients, electrical isolation of the pulmonary veins is the most important aspect of treatment,” says Dr. Calkins. “However, if a patient has persistent AF, pulmonary vein isolation alone may not be sufficient. Additional lines or a variety of adjunctive techniques may be required, but it should be noted that this was not specified in our statement.”

      Post-Procedure Anticoagulation Strategies

      The utilization of anticoagulation strategies is crucial in the post-procedural management of catheter and surgical ablation of AF (Table 2). “During the procedure, patients must be aggressively anticoagulated in order to maintain an activated clotting time, or ACT, level between 300 and 400 seconds,” says Dr. Calkins. “Following the procedure, patients should be systemically anticoagulated for 2 months. Physicians must be conservative and base the need for warfarin on the patient’s risk factors for stroke and not on the success of the procedure or the presence of AF. A desire to stop the use of the agent or systemic anticoagulation is not an appropriate indication for the procedure.”

      A Valuable Resource for Many

      Dr. Calkins says that the consensus statement may be used as a comprehensive reference. “It’s relevant not only to physicians who perform AF procedures or are considering performing an AF procedure, but also to providers who refer patients for an AF procedure and those involved in the long-term follow-up of patients who have undergone this procedure.”

      Dr. Calkins has indicated to Physician’s Weekly that he has worked as a consultant for Prorhythm, CryoCor, Ablation Frontiers, and Biosense Webster, and as a paid speaker for Biosense Webster, Boston Scientific, and AtriCure.