Recommendations and General Considerations
Shown in Table 2, and summarized in Figures 7 and 8 of this document, are the Consensus Indications for Catheter and Surgical Ablation of AF. As outlined in the introduction section of this document, these indications are stratified as Class I, Class IIa, Class IIb, and Class III indications. The evidence supporting these indications is provided, as well as a selection of the key references supporting these levels of evidence. In making these recommendations, the writing group considered the body of published literature that has defined the safety and efficacy of catheter and surgical ablation of AF. Also considered in these recommendations is the personal lifetime experience in the field of each of the writing group members. Both the number of clinical trials and the quality of these trials were considered. In considering the class of indications recommended by this writing group, it is important to keep several points in mind. First, these classes of indications only define the indications for catheter and surgical ablation of AF when performed by an electrophysiologist or a surgeon who has received appropriate training and/or who has a certain level of experience and is performing the procedure in an experienced center (Section 11). Catheter and surgical ablation of AF are highly complex procedures, and a careful assessment of the benefit and risk must be considered for each patient. Second, these indications stratify patients based only on the type of AF and whether the procedure is being performed prior to or following a trial of one or more Class I or III antiarrhythmic medications. This document for the first time includes indications for catheter ablation of select asymptomatic patients. As detailed in Section 9, there are many other additional clinical and imaging-based variables that can be used to further define the efficacy and risk of ablation in a given patient. Some of the variables that can be used to define patients in whom a lower success rate or a higher complication rate can be expected include the presence of concomitant heart disease, obesity, sleep apnea, LA size, patient age and frailty, as well as the duration of time the patient has been in continuous AF. Each of these variables needs to be considered when discussing the risks and benefits of AF ablation with a particular patient. In the presence of substantial risk or anticipated difficulty of ablation, it could be more appropriate to use additional AAD options, even if the patient on face value might present with a Class I or IIa indication for ablation. Third, it is important to consider patient preference and values. Some patients are reluctant to consider a major procedure or surgery and have a strong preference for a pharmacological approach. In these patients, trials of antiarrhythmic agents including amiodarone might be preferred to catheter ablation. On the other hand, some patients prefer a nonpharmacological approach. Fourth, it is important to recognize that some patients early in the course of their AF journey might have only infrequent episodes for many years and/or could have AF that is responsive to well-tolerated AAD therapy. And Finally, it is important to bear in mind that a decision to perform catheter or surgical AF ablation should only be made after a patient carefully considers the risks, benefits, and alternatives to the procedure.
As demonstrated in a large number of published studies, the primary clinical benefit from catheter ablation of AF is an improvement in QOL resulting from elimination of arrhythmia-related symptoms, such as palpitations, fatigue, or effort intolerance (see Section 9). Thus, the primary selection criterion for catheter ablation should be the presence of symptomatic AF. The indications for catheter and surgical ablation of symptomatic AF shown in Table 2, and summarized in Figures 7 and 8, are for the most part consistent with the indications for AF ablation recommended in the recently published 2016 ESC Guidelines for the Management of AF, as well as in the 2014 ACC/AHA/HRS Guidelines for AF management.5,6 These recommendations for AF ablation present the indications for AF ablation as second-line therapy, after failure of a Class I or III antiarrhythmic agent and also the indications for AF ablation as first-line therapy. As shown in Table 2, catheter ablation is recommended for patients with symptomatic PAF who have failed AAD therapy (Class I, LOE A). For patients with symptomatic persistent AF who have failed AAD therapy, catheter ablation has a Class IIa, LOE B-NR indication, and for patients with symptomatic long-standing persistent AF who have failed drug therapy, catheter ablation has a Class IIb, LOE C-LD indication.
In preparing this document, the writing group has chosen to address for the first time the important issue of catheter ablation of AF in select asymptomatic patients. We have also addressed the important issues of AF ablation as first-line therapy, the role of AF ablation in patients with HF, and the role of AF ablation in subgroups of patients not well represented in clinical trials. Each of these important considerations is addressed in detail below.