2017 HRS/EHRA/ECAS/APHRS/SOLAECE
expert consensus statement on catheter
and surgical ablation of atrial fibrillation:
Executive summary
Hugh Calkins, MD (Chair),1 Gerhard Hindricks, MD (Vice-Chair),2*
Riccardo Cappato, MD (Vice-Chair),3¶ Young-Hoon Kim, MD, PhD (Vice-Chair),4§
Eduardo B. Saad, MD, PhD (Vice-Chair),5‡ Luis Aguinaga, MD, PhD,6‡
Joseph G. Akar, MD, PhD,7 Vinay Badhwar, MD,8# Josep Brugada, MD, PhD,9*
John Camm, MD,10* Peng-Sheng Chen, MD,11 Shih-Ann Chen, MD,12§
Mina K. Chung, MD,13 Jens Cosedis Nielsen, DMSc, PhD,14* Anne B. Curtis, MD,15‖
D. Wyn Davies, MD,16¶ John D. Day, MD,17 Andre´ d’Avila, MD, PhD,18‡‡
N.M.S. (Natasja) de Groot, MD, PhD,19* Luigi Di Biase, MD, PhD,20*
Mattias Duytschaever, MD, PhD,21* James R. Edgerton, MD,22#
Kenneth A. Ellenbogen, MD,23 Patrick T. Ellinor, MD, PhD,24
Sabine Ernst, MD, PhD,25* Guilherme Fenelon, MD, PhD,26‡
Edward P. Gerstenfeld, MS, MD,27 David E. Haines, MD,28
Michel Haissaguerre, MD,29* Robert H. Helm, MD,30 Elaine Hylek, MD, MPH,31
Correspondence: Heart Rhythm Society, 1325 G Street NW, Suite 400, Washington, DC 20005. E-mail address: clinicaldocs@hrsonline.org.
*Representative of the European Heart Rhythm Association (EHRA)
†Representative of the American Heart Association (AHA)
‡Representative of the Sociedad Latinoamericana de Estimulacio´n Cardı´aca y Electrofisiologı´a (SOLAECE)
§Representative of the Asia Pacific Heart Rhythm Society (APHRS)
kRepresentative of the American College of Cardiology (ACC)
¶Representative of the European Cardiac Arrhythmia Society (ECAS)
#Representative of the Society of Thoracic Surgeons (STS)
**Representative of the Canadian Heart Rhythm Society (CHRS)
††Representative of the Japanese Heart Rhythm Society (JHRS)
‡‡Representative of the Sociedade Brasileira de Arritmias Cardı´acas (SOBRAC)
Developed in partnership with and endorsed by the European Heart Rhythm Association (EHRA), the European Cardiac Arrhythmia Society (ECAS), the Asia Pacific Heart Rhythm
Society (APHRS), and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulacio´n Cardı´aca y Electrofisiologı´a [SOLAECE]).
Developed in collaboration with and endorsed by the Society of Thoracic Surgeons (STS), the American College of Cardiology (ACC), the American Heart Association (AHA), the
Canadian Heart Rhythm Society (CHRS), the Japanese Heart Rhythm Society (JHRS), and the Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardı´acas
[SOBRAC]). Chair: Hugh Calkins, MD, Johns Hopkins Medical Institutions, Baltimore, MD, USA. Section Chairs: Definitions, Mechanisms, and Rationale for AF Ablation: Shih-
Ann Chen, MD, National Yang-Ming University, Taipei, Taiwan. Modifiable Risk Factors for AF and Impact on Ablation: Jonathan M. Kalman, MBBS, PhD, Royal Melbourne
Hospital and University of Melbourne, Melbourne, Australia. Indications: Claudio Tondo, MD, PhD, Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS,
Department of Cardiovascular Sciences, University of Milan, Milan, Italy. Strategies, Techniques, and Endpoints: Karl Heinz Kuck, MD, PhD, Asklepios Klinik St. Georg, Hamburg,
Germany. Technology and Tools: Andrea Natale, MD, Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA. Technical Aspects of Ablation to
Maximize Safety and Anticoagulation: David E. Haines, MD, Beaumont Health System, Royal Oak, MI, USA. Follow-up Considerations: Francis E. Marchlinski, MD, Hospital of the
University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. Outcomes and Efficacy: Matthew R. Reynolds, MD, MSc, Lahey Hospital and Medical
Center, Burlington, MA, USA. Complications: D. Wyn Davies, MD, Imperial College Healthcare NHS Trust, London, United Kingdom. Training Requirements: Bruce D. Lindsay, MD,
Cleveland Clinic, Cleveland, OH, USA. Surgical and Hybrid AF Ablation: James R. Edgerton, MD, The Heart Hospital, Baylor Plano, Plano, TX, USA. Clinical Trial Design: Atul
Verma, MD, Southlake Regional Health Centre, University of Toronto, Toronto, Canada.
VC 2017 HRS; EHRA, a registered branch of the ESC; ECAS; JHRS and APHRS; and SOLAECE. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/). For commercial re-use, please contact journals.permissions@oup.com
Europace (2018) 20, 157–208 EHRA CONSENSUS DOCUMENT
doi:10.1093/europace/eux275
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Warren M. Jackman, MD,32 Jose Jalife, MD,33 Jonathan M. Kalman, MBBS, PhD,34§
Josef Kautzner, MD, PhD,35* Hans Kottkamp, MD,36* Karl Heinz Kuck, MD, PhD,37*
Koichiro Kumagai, MD, PhD,38§ Richard Lee, MD, MBA,39#
Thorsten Lewalter, MD, PhD,40¶ Bruce D. Lindsay, MD,41 Laurent Macle, MD,42**
Moussa Mansour, MD,43 Francis E. Marchlinski, MD,44 Gregory F. Michaud, MD,45†
Hiroshi Nakagawa, MD, PhD,46 Andrea Natale, MD,47 Stanley Nattel, MD,48
Ken Okumura, MD, PhD,49†† Douglas Packer, MD,50 Evgeny Pokushalov, MD, PhD,51*
Matthew R. Reynolds, MD, MSc,52 Prashanthan Sanders, MBBS, PhD,53
Mauricio Scanavacca, MD, PhD,54‡ Richard Schilling, MD,55*
Claudio Tondo, MD, PhD,56* Hsuan-Ming Tsao, MD,57§ Atul Verma, MD,58
David J. Wilber, MD,59 Teiichi Yamane, MD, PhD60††
Document Reviewers: Carina Blomstro¨m-Lundqvist, MD, PhD; Angelo A.V. De Paola, MD, PhD;
Peter M. Kistler, MBBS, PhD; Gregory Y.H. Lip, MD; Nicholas S. Peters, MD;
Cristiano F. Pisani, MD; Antonio Raviele, MD; Eduardo B. Saad, MD, PhD; Kazuhiro Satomi, MD, PhD;
Martin K. Stiles, MB ChB, PhD; StephanWillems, MD, PhD
From the 1Johns Hopkins Medical Institutions, Baltimore, MD; 2Heart Center Leipzig, Leipzig, Germany; 3Humanitas Research Hospital, Arrhythmias and Electrophysiology
Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research
Center, Milan, Italy); 4Korea University, Seoul, South Korea; 5Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil; 6Centro Privado de Cardiologı´a,
Tucuman, Argentina; 7Yale University School of Medicine, New Haven, CT; 8West Virginia University School of Medicine, Morgantown, WV; 9Cardiovascular Institute, Hospital
Clı´nic, University of Barcelona, Catalonia, Spain; 10St. George’s University of London, London, United Kingdom; 11Indiana University School of Medicine, Indianapolis, IN;
12National Yang-Ming University, Taipei, Taiwan; 13Cleveland Clinic, Cleveland, OH; 14Aarhus University Hospital, Skejby, Denmark; 15University at Buffalo, Buffalo, NY;
16Imperial College Healthcare NHS Trust, London, United Kingdom; 17Intermountain Medical Center Heart Institute, Salt Lake City, UT; 18Hospital SOS Cardio, Florianopolis,
SC, Brazil; 19Erasmus Medical Center, Rotterdam, the Netherlands; 20Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY;
21Universitair Ziekenhuis Gent (Ghent University Hospital), Ghent, Belgium; 22The Heart Hospital, Baylor Plano, Plano, TX; 23Virginia Commonwealth University School of
Medicine, Richmond, VA; 24Massachusetts General Hospital, Boston, MA; 25Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial
College London, London, United Kingdom; 26Albert Einstein Jewish Hospital, Federal University of S~ao Paulo, S~ao Paulo, Brazil; 27University of California, San Francisco, San
Francisco, CA; 28Beaumont Health System, Royal Oak, MI; 29Hoˆpital Cardiologique du Haut-Le´veˆque, Pessac, France; 30Boston University Medical Center, Boston, MA; 31Boston
University School of Medicine, Boston, MA; 32Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK; 33University of Michigan, Ann Arbor,
MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain; 34Royal Melbourne Hospital and University of Melbourne, Melbourne,
Australia; 35Institute for Clinical and Experimental Medicine, Prague, Czech Republic; 36Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland; 37Asklepios
Klinik St. Georg, Hamburg, Germany; 38Heart RhythmCenter, Fukuoka Sanno Hospital, Fukuoka, Japan; 39Saint Louis University Medical School, St. Louis, MO; 40Department of
Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany; 41Cleveland Clinic, Cleveland, OH; 42Montreal Heart Institute, Department of Medicine,
Universite´ de Montre´al, Montre´al, Canada; 43Massachusetts General Hospital, Boston, MA; 44Hospital of the University of Pennsylvania, University of Pennsylvania School of
Medicine, Philadelphia, PA; 45Brigham and Women’s Hospital, Boston, MA; 46Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK;
47Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX; 48Montreal Heart Institute and Universite´ de Montre´al, Montreal, Canada, McGill University,
Montreal, Canada, and University Duisburg-Essen, Essen, Germany; 49Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan; 50Mayo Clinic, Rochester, MN;
51State Research Institute of Circulation Pathology, Novosibirsk, Russia; 52Lahey Hospital and Medical Center, Burlington, MA; 53Centre for Heart Rhythm Disorders, South
Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia; 54Instituto do Corac¸~ao (InCor), S~ao Paulo, Brazil;
55Barts Heart Centre, London, United Kingdom; 56Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences,
University of Milan, Milan, Italy; 57National Yang-Ming University Hospital, Yilan City, Taiwan; 58Southlake Regional Health Centre, University of Toronto, Toronto, Canada;
59Loyola University of Chicago, Chicago, IL; and 60Jikei University School of Medicine, Tokyo, Japan
Online publish-ahead-of-print 15 September 2017
...................................................................................................................................................................................................
Keywords Ablation • Arrhythmia • Atrial fibrillation • Atrial flutter • Atrial tachycardia • Catheter
ablation • Surgical ablation • Stroke • Anticoagulation
Table of Contents
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159
Section 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159
Section 2: Definitions, Mechanisms, and Rationale for AF Ablation . . . .163
Section 3: Modifiable Risk Factors for AF and Impact on Ablation . . . . .163
Section 4: Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163
Section 5: Strategies, Techniques, and Endpoints . . . . . . . . . . . . . . . . . . . . .166
Section 6: Technology and Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166
Section 7: Technical Aspects of Ablation to Maximize Safety and
Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166
Section 8: Follow-up Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .167
Section 9: Outcomes and Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176
Section 10: Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176
Section 11: Training Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182
Section 12: Surgical and Hybrid AF Ablation . . . . . . . . . . . . . . . . . . . . . . . . .182
Section 13: Clinical Trial Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182
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Unanswered Questions in AF Ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182
Section 14: Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198
Appendix A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187
Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .196
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198
Abbreviations
AAD antiarrhythmic drug
AF atrial fibrillation
AFL atrial flutter
CB cryoballoon
CFAE complex fractionated atrial electrogram
LA left atrial
LAA left atrial appendage
LGE late gadolinium-enhanced
LOE level of evidence
MRI magnetic resonance imaging
OAC oral anticoagulation
RF radiofrequency
Section 1: Introduction
During the past three decades, catheter and surgical ablation of atrial
fibrillation (AF) have evolved from investigational procedures to their
current role as effective treatment options for patients with AF.
Surgical ablation of AF, using either standard, minimally invasive, or
hybrid techniques, is available in most major hospitals throughout the
world. Catheter ablation of AF is even more widely available, and is
now the most commonly performed catheter ablation procedure.
In 2007, an initial Consensus Statement on Catheter and Surgical AF
Ablation was developed as a joint effort of the Heart Rhythm Society
(HRS), the European Heart Rhythm Association (EHRA), and the
European Cardiac Arrhythmia Society (ECAS).1 The 2007 document
was also developed in collaboration with the Society of Thoracic
Surgeons (STS) and the American College of Cardiology (ACC). This
Consensus Statement on Catheter and Surgical AF Ablation was
rewritten in 2012 to reflect the many advances in AF ablation that had
occurred in the interim.2 The rate of advancement in the tools, tech-
niques, and outcomes of AF ablation continue to increase as enormous
research efforts are focused on the mechanisms, outcomes, and treat-
ment of AF. For this reason, the HRS initiated an effort to rewrite and
update this Consensus Statement. Reflecting both the worldwide im-
portance of AF, as well as the worldwide performance of AF ablation,
this document is the result of a joint partnership between the HRS,
EHRA, ECAS, the Asia Pacific Heart Rhythm Society (APHRS), and the
Latin American Society of Cardiac Stimulation and Electrophysiology
(Sociedad Latinoamericana de Estimulacio´n Cardı´aca y Electrofisiologı´a
[SOLAECE]). The purpose of this 2017 Consensus Statement is to
provide a state-of-the-art review of the field of catheter and surgical
ablation of AF and to report the findings of a writing group, convened
by these five international societies. The writing group is charged with
defining the indications, techniques, and outcomes of AF ablation pro-
cedures. Included within this document are recommendations pertin-
ent to the design of clinical trials in the field of AF ablation and the
reporting of outcomes, including definitions relevant to this topic.
The writing group is composed of 60 experts representing 11 or-
ganizations: HRS, EHRA, ECAS, APHRS, SOLAECE, STS, ACC,
American Heart Association (AHA), Canadian Heart Rhythm Society
(CHRS), Japanese Heart Rhythm Society (JHRS), and Brazilian
Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias
Cardı´acas [SOBRAC]). All the members of the writing group, as well
as peer reviewers of the document, have provided disclosure
Table 1 Atrial fibrillation definitions
AF episode An AF episode is defined as AF that is documented by ECG monitoring or intracardiac electrogram monitoring and has
a duration of at least 30 seconds, or if less than 30 seconds, is present throughout the ECG monitoring tracing. The
presence of subsequent episodes of AF requires that sinus rhythm be documented by ECG monitoring between AF
episodes.
Chronic AF Chronic AF has variable definitions and should not be used to describe populations of AF patients undergoing AF
ablation.
Early persistent AF Early persistent AF is defined as AF that is sustained beyond 7 days but is less than 3 months in duration.
Lone AF Lone AF is a historical descriptor that is potentially confusing and should not be used to describe populations of pa-
tients with AF undergoing AF ablation.
Long-standing persistent AF Long-standing persistent AF is defined as continuous AF of greater than 12 months’ duration.
Paroxysmal AF Paroxysmal AF is defined as AF that terminates spontaneously or with intervention within 7 days of onset.
Permanent AF Permanent AF is defined as the presence of AF that is accepted by the patient and physician, and for which no further
attempts to restore or maintain sinus rhythm will be undertaken. The term permanent AF represents a therapeutic at-
titude on the part of the patient and physician rather than an inherent pathophysiological attribute of AF. The term
permanent AF should not be used within the context of a rhythm control strategy with antiarrhythmic drug therapy
or AF ablation.
Persistent AF Persistent AF is defined as continuous AF that is sustained beyond 7 days.
Silent AF Silent AF is defined as asymptomatic AF diagnosed with an opportune ECG or rhythm strip.
AF, atrial fibrillation; ECG, electrocardiogram.
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statements for all relationships that might be perceived as real or po-
tential conflicts of interest. All author and peer reviewer disclosure
information is provided in Appendix A and Appendix B.
In writing a consensus document, it is recognized that consensus
does not mean that there was complete agreement among all the
writing group members. Surveys of the entire writing group were
used to identify areas of consensus concerning performance of AF
ablation procedures and to develop recommendations concerning
the indications for catheter and surgical AF ablation. These recom-
mendations were systematically balloted by the 60 writing group
members and were approved by a minimum of 80% of these mem-
bers. The recommendations were also subject to a 1-month public
comment period. Each partnering and collaborating organization
then officially reviewed, commented on, edited, and endorsed the
final document and recommendations.
The grading system for indication of class of evidence level was
adapted based on that used by the ACC and the AHA.3,4 It is im-
portant to state, however, that this document is not a guideline.
The indications for catheter and surgical ablation of AF, as well as
recommendations for procedure performance, are presented
with a Class and Level of Evidence (LOE) to be consistent with
what the reader is familiar with seeing in guideline statements. A
Class I recommendation means that the benefits of the AF ablation
procedure markedly exceed the risks, and that AF ablation should
be performed; a Class IIa recommendation means that the benefits
of an AF ablation procedure exceed the risks, and that it is
Figure 1 Anatomical drawings of the heart relevant to AF ablation. This series of drawings shows the heart and associated relevant structures
from four different perspectives relevant to AF ablation. This drawing includes the phrenic nerves and the esophagus. (A) The heart viewed from the
anterior perspective. (B) The heart viewed from the right lateral perspective. (C) The heart viewed from the left lateral perspective. (D) The heart
viewed from the posterior perspective. (E) The left atrium viewed from the posterior perspective. Illustration: Tim Phelps VC 2017 Johns Hopkins
University, AAM.
160 Guidelines
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Figure 2 This figure includes six CT or MR images of the left atrium and pulmonary veins viewed from the posterior perspective. Common and un-
common variations in PV anatomy are shown. (A) Standard PV anatomy with 4 distinct PV ostia. (B) Variant PV anatomy with a right common and a
left common PV. (C) Variant PV anatomy with a left common PV with a short trunk and an anomolous PV arising from the right posterior left atrial
wall. (D) and (E) Variant PV anatomy with a common left PV with a long trunk. (F) Variant PV anatomy with a massive left common PV.
Figure 3 Schematic drawing showing various hypotheses and proposals concerning the mechanisms of atrial fibrillation. (A) Multiple wavelets hy-
pothesis. (B) Rapidly discharging automatic foci. (C) Single reentrant circuit with fibrillatory conduction. (D) Functional reentry resulting from rotors
or spiral waves. (E) AF maintenance resulting from dissociation between epicardial and endocardial layers, with mutual interaction producing multi-
plying activity that maintains the arrhythmia.
Guidelines 161
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reasonable to perform AF ablation; a Class IIb recommendation
means that the benefit of AF ablation is greater or equal to the
risks, and that AF ablation may be considered; and a Class III rec-
ommendation means that AF ablation is of no proven benefit and
is not recommended.
The writing group reviewed and ranked evidence supporting cur-
rent recommendations with the weight of evidence ranked as Level
A if the data were derived from high-quality evidence from more
than one randomized clinical trial, meta-analyses of high-quality
randomized clinical trials, or one or more randomized clinical trials
corroborated by high-quality registry studies. The writing group
ranked available evidence as Level B-R when there was moderate-
quality evidence from one or more randomized clinical trials, or
meta-analyses of moderate-quality randomized clinical trials. Level B-
NR was used to denote moderate-quality evidence from one or
more well-designed, well-executed nonrandomized studies, observa-
tional studies, or registry studies. This designation was also used to
denote moderate-quality evidence from meta-analyses of such stud-
ies. Evidence was ranked as Level C-LD when the primary source of
the recommendation was randomized or nonrandomized observa-
tional or registry studies with limitations of design or execution,
meta-analyses of such studies, or physiological or mechanistic studies
of human subjects. Level C-EO was defined as expert opinion based
on the clinical experience of the writing group.
Despite a large number of authors, the participation of several
societies and professional organizations, and the attempts of the
group to reflect the current knowledge in the field adequately, this
document is not intended as a guideline. Rather, the group would
like to refer to the current guidelines on AF management for the
purpose of guiding overall AF management strategies.5,6 This con-
sensus document is specifically focused on catheter and surgical
ablation of AF, and summarizes the opinion of the writing group
members based on an extensive literature review as well as their
own experience. It is directed to all health care professionals who
are involved in the care of patients with AF, particularly those who
are caring for patients who are undergoing, or are being con-
sidered for, catheter or surgical ablation procedures for AF, and
those involved in research in the field of AF ablation. This
Figure 4 Structure and mechanisms of atrial fibrillation. (A) Schematic drawing of the left and right atria as viewed from the posterior perspective.
The extension of muscular fibers onto the PVs can be appreciated. Shown in yellow are the five major left atrial autonomic ganglionic plexi (GP) and
axons (superior left GP, inferior left GP, anterior right GP, inferior right GP, and ligament of Marshall). Shown in blue is the coronary sinus, which is
enveloped by muscular fibers that have connections to the atria. Also shown in blue is the vein and ligament of Marshall, which travels from the cor-
onary sinus to the region between the left superior PV and the left atrial appendage. (B) The large and small reentrant wavelets that play a role in ini-
tiating and sustaining AF. (C) The common locations of PV (red) and also the common sites of origin of non-PV triggers (shown in green). (D)
Composite of the anatomic and arrhythmic mechanisms of AF. Adapted with permission from Calkins et al. Heart Rhythm 2012; 9:632–696.e21.2
162 Guidelines
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statement is not intended to recommend or promote catheter or
surgical ablation of AF. Rather, the ultimate judgment regarding
care of a particular patient must be made by the health care pro-
vider and the patient in light of all the circumstances presented by
that patient.
The main objective of this document is to improve patient care by
providing a foundation of knowledge for those involved with catheter
ablation of AF. A second major objective is to provide recommenda-
tions for designing clinical trials and reporting outcomes of clinical tri-
als of AF ablation. It is recognized that this field continues to evolve
rapidly. As this document was being prepared, further clinical trials of
catheter and surgical ablation of AF were under way.
Section 2: Definitions,
Mechanisms, and Rationale for AF
Ablation
This section of the document provides definitions for use in the diag-
nosis of AF. This section also provides an in-depth review of the
mechanisms of AF and rationale for catheter and surgical AF ablation
(Table 1, Figures 1–6).
Section 3: Modifiable Risk Factors
for AF and Impact on Ablation
Management of patients with AF has traditionally consisted of three
main components: (1) anticoagulation for stroke prevention; (2) rate
control; and (3) rhythm control. With the emergence of large
amounts of data, which have both defined and called attention to the
interaction between modifiable risk factors and the development of
AF and outcomes of AF management, we believe it is time to include
risk factor modification as the fourth pillar of AF management. This
section of the document reviews the link between modifiable risk fac-
tors and both the development of AF and their impacts on the out-
comes of AF ablation.
Section 4: Indications
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 indi-
cations. The evidence supporting these indications is provided, as
well as a selection of the key references supporting these levels of
Figure 5 Schematic drawing showing mechanisms of atrial flutter and atrial tachycardia. (A) Isthmus-dependent reverse common (clockwise) atrial
flutter. (B) Isthmus-dependent common (counter clockwise) atrial flutter. (C) Focal atrial tachycardia with circumferential spread of activation of the
atria (can arise from multiple sites within the left and right atrium). (D) Microreentrant atrial tachycardia with circumferential spread of activation of
the atria. (E) Perimitral atrial flutter. (F) Roof-dependent atrial flutter.
Guidelines 163
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evidence. In making these recommendations, the writing group con-
sidered 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 clin-
ical trials and the quality of these trials were considered. In consider-
ing the class of indications recommended by this writing group, it is
important to keep several points in mind. First, these classes of indica-
tions 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 ex-
perience 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 pa-
tients 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 in-
cludes indications for catheter ablation of select asymptomatic pa-
tients. 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 vari-
ables that can be used to define patients in whom a lower success
rate or a higher complication rate can be expected include the pres-
ence of concomitant heart disease, obesity, sleep apnea, left atrial
(LA) size, patient age and frailty, as well as the duration of time the pa-
tient 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
antiarrhythmic drug (AAD) options, even if the patient on face value
might present with a Class I or IIa indication for ablation. Third, it is
Figure 6 Schematic of common lesion sets employed in AF ablation. (A) The circumferential ablation lesions that are created in a circumferential
fashion around the right and the left PVs. The primary endpoint of this ablation strategy is the electrical isolation of the PV musculature. (B) Some of
the most common sites of linear ablation lesions. These include a “roof line” connecting the lesions encircling the left and/or right PVs, a “mitral isth-
mus” line connecting the mitral valve and the lesion encircling the left PVs at the end of the left inferior PV, and an anterior linear lesion connecting ei-
ther the “roof line” or the left or right circumferential lesion to the mitral annulus anteriorly. A linear lesion created at the cavotricuspid isthmus is
also shown. This lesion is generally placed in patients who have experienced cavotricuspid isthmus-dependent atrial flutter clinically or have it induced
during EP testing. (C) Similar to 6B, but also shows additional linear ablation lesions between the superior and inferior PVs resulting in a figure of eight
lesion sets as well as a posterior inferior line allowing for electrical isolation of the posterior left atrial wall. An encircling lesion of the superior vena
cava (SVC) directed at electrical isolation of the SVC is also shown. SVC isolation is performed if focal firing from the SVC can be demonstrated. A
subset of operators empirically isolates the SVC. (D) Representative sites for ablation when targeting rotational activity or CFAEs are targeted.
Modified with permission from Calkins et al. Heart Rhythm 2012; 9:632–696.e21.2
164 Guidelines
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Table 2 Indications for catheter (A and B) and surgical (C, D, and E) ablation of atrial fibrillation
Recommendation Class LOE References
Indications for catheter ablation of atrial fibrillation
A. Indications for catheter ablation of atrial fibrillation
Symptomatic AF refractory or in-
tolerant to at least one Class I or
III antiarrhythmic medication
Paroxysmal: Catheter ablation is recommended. I A 7–18
Persistent: Catheter ablation is reasonable. IIa B-NR 8,16–26
Long-standing persistent: Catheter ablation may be
considered.
IIb C-LD 8,16–26
Symptomatic AF prior to initiation
of antiarrhythmic therapy with a
Class I or III antiarrhythmic
medication
Paroxysmal: Catheter ablation is reasonable. IIa B-R 27–35
Persistent: Catheter ablation is reasonable. IIa C-EO
Long-standing persistent: Catheter ablation may be
considered.
IIb C-EO
B. Indications for catheter atrial fibrillation ablation in populations of patients not well represented in clinical trials
Congestive heart failure It is reasonable to use similar indications for AF abla-
tion in selected patients with heart failure as in pa-
tients without heart failure.
IIa B-R 36–52
Older patients (>75 years of age) It is reasonable to use similar indications for AF abla-
tion in selected older patients with AF as in
younger patients.
IIa B-NR 53–59
Hypertrophic cardiomyopathy It is reasonable to use similar indications for AF abla-
tion in selected patients with HCM as in patients
without HCM.
IIa B-NR 60–62
Young patients (<45 years of age) It is reasonable to use similar indications for AF abla-
tion in young patients with AF (<45 years of age)
as in older patients.
IIa B-NR 63,64
Tachy-brady syndrome It is reasonable to offer AF ablation as an alternative
to pacemaker implantation in patients with tachy-
brady syndrome.
IIa B-NR 33–35
Athletes with AF It is reasonable to offer high-level athletes AF as
first-line therapy due to the negative effects of
medications on athletic performance.
IIa C-LD 27,28,65
Asymptomatic AF** Paroxysmal: Catheter ablation may be considered in
select patients.**
IIb C-EO 66,67
Persistent: Catheter ablation may be considered in
select patients.
IIb C-EO 68
Indications for surgical ablation of atrial fibrillation
C. Indications for concomitant open (such as mitral valve) surgical ablation of atrial fibrillation
Symptomatic AF refractory or in-
tolerant to at least one Class I or
III antiarrhythmic medication
Paroxysmal: Surgical ablation is recommended. I B-NR 69–82
Persistent: Surgical ablation is recommended. I B-NR 69–82
Long-standing persistent: Surgical ablation is
recommended.
I B-NR 69–82
Symptomatic AF prior to initiation
of antiarrhythmic therapy with a
Class I or III antiarrhythmic
medication
Paroxysmal: Surgical ablation is recommended. I B-NR 69–82
Persistent: Surgical ablation is recommended. I B-NR 69–82
Long-standing persistent: Surgical ablation is
recommended.
I B-NR 69–82
D. Indications for concomitant closed (such as CABG and AVR) surgical ablation of atrial fibrillation
Symptomatic AF refractory or in-
tolerant to at least one Class I or
III antiarrhythmic medication
Paroxysmal: Surgical ablation is recommended. I B-NR 83–88
Persistent: Surgical ablation is recommended. I B-NR 83–88
Long-standing persistent: Surgical ablation is
recommended.
I B-NR 83–88
Symptomatic AF prior to initiation
of antiarrhythmic therapy with a
Class I or III antiarrhythmic
medication
Paroxysmal: Surgical ablation is reasonable. IIa B-NR 83–88
Persistent: Surgical ablation is reasonable. IIa B-NR 83–88
Long-standing persistent: Surgical ablation is
reasonable.
IIa B-NR 83–88
Continued
Guidelines 165
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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 pre-
ferred 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 ab-
lation should only be made after a patient carefully considers the
risks, benefits, and alternatives to the procedure.
Section 5: Strategies, Techniques,
and Endpoints
The writing group recommendations for techniques to be used for
ablation of persistent and long-standing persistent AF (Table 3), ad-
junctive ablation strategies, nonablative strategies to improve out-
comes of AF ablation, and endpoints for ablation of paroxysmal,
persistent, and long-standing persistent AF are covered in this
section. A schematic overview of common lesion sets created during
an AF ablation procedure is shown in Figure 6.
Section 6: Technology and Tools
This section of the consensus statement provides an update on
many of the technologies and tools that are employed for AF abla-
tion procedures. It is important to recognize that this is not a com-
prehensive listing and that new technologies, tools, and
approaches are being developed. It is also important to recognize
that radiofrequency (RF) energy is the dominant energy source
available for ablation of typical and atypical atrial flutter (AFL).
Although cryoablation is a commonly employed tool for AF abla-
tion, it is not well suited for ablation of typical or atypical AFL.
Other energy sources and tools are available in some parts of the
world and/or are in various stages of development and/or clinical
investigation. Shown in Figure 9 are schematic drawings of AF abla-
tion using point-by-point RF energy (Figure 9A) and AF ablation
using the cryoballoon (CB) system (Figure 9B).
....................................................................................................................................................................................................................
Table 2 Continued
Recommendation Class LOE References
E. Indications for stand-alone and hybrid surgical ablation of atrial fibrillation
Symptomatic AF refractory or in-
tolerant to at least one Class I or
III antiarrhythmic medication
Paroxysmal: Stand-alone surgical ablation can be
considered for patients who have failed one or
more attempts at catheter ablation and also for
those who are intolerant or refractory to antiar-
rhythmic drug therapy and prefer a surgical ap-
proach, after review of the relative safety and
efficacy of catheter ablation versus a stand-alone
surgical approach.
IIb B-NR 83–85,89–103
Persistent: Stand-alone surgical ablation is reason-
able for patients who have failed one or more at-
tempts at catheter ablation and also for those
patients who prefer a surgical approach after re-
view of the relative safety and efficacy of catheter
ablation versus a stand-alone surgical approach.
IIa B-NR 83–85,89–103
Long-standing persistent: Stand-alone surgical abla-
tion is reasonable for patients who have failed
one or more attempts at catheter ablation and
also for those patients who prefer a surgical ap-
proach after review of the relative safety and effi-
cacy of catheter ablation versus a stand-alone
surgical approach.
IIa B-NR 83–85,89–103
It might be reasonable to apply the indications for
stand-alone surgical ablation described above to
patients being considered for hybrid surgical AF
ablation.
IIb C-EO 103–108
AF, atrial fibrillation; LOE, Level of Evidence; HCM, hypertrophic cardiomyopathy.
**A decision to perform AF ablation in an asymptomatic patient requires additional discussion with the patient because the potential benefits of the procedure for the patient
without symptoms are uncertain.
166 Guidelines
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Section 7: Technical Aspects of
Ablation to Maximize Safety and
Anticoagulation
Anticoagulation strategies pre-, during, and postcatheter ablation of
AF (Table 4); signs and symptoms of complications that can occur
within the first several months following ablation (Table 5); anesthesia
or sedation during ablation; and approaches to minimize risk of an
atrial esophageal fistula are discussed in this section.
Section 8: Follow-up
Considerations
AF ablation is an invasive procedure that entails risks, most of which
are present during the acute procedural period. However, complica-
tions can also occur in the weeks or months following ablation.
Recognizing common symptoms after AF ablation and distinguishing
those that require urgent evaluation and referral to an electrophysi-
ologist is an important part of follow-up after AF ablation. The suc-
cess of AF ablation is based in large part on freedom from AF
Figure 7 Indications for catheter ablation of symptomatic atrial
fibrillation. Shown in this figure are the indications for catheter abla-
tion of symptomatic paroxysmal, persistent, and long-standing per-
sistent AF. The Class for each indication based on whether ablation
is performed after failure of antiarrhythmic drug therapy or as first-
line therapy is shown. Please refer to Table 2B and the text for the
indications for catheter ablation of asymptomatic AF.
Figure 8 Indications for surgical ablation of atrial fibrillation. Shown in this figure are the indications for surgical ablation of paroxysmal, persistent,
and long-standing persistent AF. The Class for each indication based on whether ablation is performed after failure of antiarrhythmic drug therapy or
as first-line therapy is shown. The indications for surgical AF ablation are divided into whether the AF ablation procedure is performed concomitantly
with an open surgical procedure (such as mitral valve replacement), a closed surgical procedure (such as coronary artery bypass graft surgery), or as
a stand-alone surgical AF ablation procedure performed solely for treatment of atrial fibrillation.
Guidelines 167
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Table 3 Atrial fibrillation ablation: strategies, techniques, and endpoints
Recommendation Class LOE References
PV isolation by catheter ablation Electrical isolation of the PVs is recommended during all AF
ablation procedures.
I A 7–16,19–26,109
Achievement of electrical isolation requires, at a minimum,
assessment and demonstration of entrance block into the
PV.
I B-R 7–16,19–26,109
Monitoring for PV reconnection for 20 minutes following
initial PV isolation is reasonable.
IIa B-R 9,110–120
Administration of adenosine 20 minutes following initial PV
isolation using RF energy with reablation if PV reconnec-
tion might be considered.
IIb B-R 109,111–114,120–128
Use of a pace-capture (pacing along the ablation line) abla-
tion strategy may be considered.
IIb B-R 129–133
Demonstration of exit block may be considered. IIb B-NR 134–139
Ablation strategies to be considered
for use in conjunction with PV
isolation
If a patient has a history of typical atrial flutter or typical
atrial flutter is induced at the time of AF ablation, delivery
of a cavotricuspid isthmus linear lesion is recommended.
I B-R 140–143
If linear ablation lesions are applied, operators should use
mapping and pacing maneuvers to assess for line
completeness.
I C-LD 19,141–149
If a reproducible focal trigger that initiates AF is identified
outside the PV ostia at the time of an AF ablation proced-
ure, ablation of the focal trigger should be considered.
IIa C-LD 150–161
When performing AF ablation with a force-sensing RF abla-
tion catheter, a minimal targeted contact force of 5 to 10
grams is reasonable.
IIa C-LD 13,14,128,162–178
Posterior wall isolation might be considered for initial or re-
peat ablation of persistent or long-standing persistent AF.
IIb C-LD 21,179–185
Administration of high-dose isoproterenol to screen for and
then ablate non-PV triggers may be considered during ini-
tial or repeat AF ablation procedures in patients with par-
oxysmal, persistent, or long-standing persistent AF.
IIb C-LD 150–161
DF-based ablation strategy is of unknown usefulness for AF
ablation.
IIb C-LD 186–193
The usefulness of creating linear ablation lesions in the right
or left atrium as an initial or repeat ablation strategy for
persistent or long-standing persistent AF is not well
established.
IIb B-NR 19,20,142,145–149,194–201
The usefulness of linear ablation lesions in the absence of
macroreentrant atrial flutter is not well established.
IIb C-LD 19,20,142,145–149,194–201
The usefulness of mapping and ablation of areas of abnormal
myocardial tissue identified with voltage mapping or MRI
as an initial or repeat ablation strategy for persistent or
long-standing persistent AF is not well established.
IIb B-R 179,202–211
The usefulness of ablation of complex fractionated atrial
electrograms as an initial or repeat ablation strategy for
persistent and long-standing persistent AF is not well
established.
IIb B-R 19,20,195–197,212–220
The usefulness of ablation of rotational activity as an initial
or repeat ablation strategy for persistent and long-stand-
ing persistent AF is not well established.
IIb B-NR 221–241
The usefulness of ablation of autonomic ganglia as an initial
or repeat ablation strategy for paroxysmal, persistent,
and long-standing persistent AF is not well established.
IIb B-NR 19,89,242–259
Continued
168 Guidelines
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Table 3 Continued
Recommendation Class LOE References
Nonablation strategies to improve
outcomes
Weight loss can be useful for patients with AF, including
those who are being evaluated to undergo an AF ablation
procedure, as part of a comprehensive risk factor man-
agement strategy.
IIa B-R 260–288
It is reasonable to consider a patient’s BMI when discussing
the risks, benefits, and outcomes of AF ablation with a pa-
tient being evaluated for an AF ablation procedure.
IIa B-R 260–288
It is reasonable to screen for signs and symptoms of sleep
apnea when evaluating a patient for an AF ablation pro-
cedure and to recommend a sleep evaluation if sleep
apnea is suspected.
IIa B-R 270,276–278,289–307
Treatment of sleep apnea can be useful for patients with AF,
including those who are being evaluated to undergo an
AF ablation procedure.
IIa B-R 270,276–278,289–307
The usefulness of discontinuation of antiarrhythmic drug
therapy prior to AF ablation in an effort to improve long-
term outcomes is unclear.
IIb C-LD 308–312
The usefulness of initiation or continuation of antiarrhyth-
mic drug therapy during the postablation healing phase in
an effort to improve long-term outcomes is unclear.
IIb C-LD 308–312
Strategies to reduce the risks of AF
ablation
Careful identification of the PV ostia is mandatory to avoid
ablation within the PVs.
I B-NR 313–335
It is recommended that RF power be reduced when creat-
ing lesions along the posterior wall near the esophagus.
I C-LD 68,336–365
It is reasonable to use an esophageal temperature probe
during AF ablation procedures to monitor esophageal
temperature and help guide energy delivery.
IIa C-EO 68,336,345,365
AF, atrial fibrillation; LOE, Level of Evidence; PV, pulmonary vein; RF, radiofrequency; MRI, magnetic resonance imaging; BMI, body mass index.
Figure 9 Schematic drawing showing catheter ablation of atrial fibrillation using either RF energy or cryoballoon AF ablation. (A) Shows a typical
wide area lesion set created using RF energy. Ablation lesions are delivered in a figure of eight pattern around the left and right PV veins. Also shown
is a linear cavotricuspid isthmus lesion created for ablation of typical atrial flutter in a patient with a prior history of typical atrial flutter or inducible
isthmus-dependent typical atrial flutter at the time of ablation. A multielectrode circular mapping catheter is positioned in the left inferior PV. (B)
Shows an ablation procedure using the cryoballoon system. Ablation lesions have been created surrounding the right PVs, and the cryoballoon abla-
tion catheter is positioned in the left superior PV. A through the lumen multielectrode circular mapping catheter is positioned in the left superior PV.
Illustration: Tim PhelpsVC 2017 Johns Hopkins University, AAM.
Guidelines 169
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Table 4 Anticoagulation strategies: pre-, during, and postcatheter ablation of AF
Recommendation Class LOE References
Preablation For patients undergoing AF catheter ablation who have been therapeutically
anticoagulated with warfarin or dabigatran, performance of the ablation pro-
cedure without interruption of warfarin or dabigatran is recommended.
I A 366–373
For patients undergoing AF catheter ablation who have been therapeutically
anticoagulated with rivaroxaban, performance of the ablation procedure
without interruption of rivaroxaban is recommended.
I B-R 374
For patients undergoing AF catheter ablation who have been therapeutically
anticoagulated with a NOAC other than dabigatran or rivaroxaban, per-
formance of the ablation procedure without withholding a NOAC dose is
reasonable.
IIa B-NR 375
Anticoagulation guidelines that pertain to cardioversion of AF should be
adhered to in patients who present for an AF catheter ablation procedure.
I B-NR 5,6
For patients anticoagulated with a NOAC prior to AF catheter ablation, it is
reasonable to hold one to two doses of the NOAC prior to AF ablation
with reinitiation postablation.
IIa B-NR 372,376–380
Performance of a TEE in patients who are in AF on presentation for AF cath-
eter ablation and who have been receiving anticoagulation therapeutically
for 3 weeks or longer is reasonable.
IIa C-EO 5,6
Performance of a TEE in patients who present for ablation in sinus rhythm and
who have not been anticoagulated prior to catheter ablation is reasonable.
IIa C-EO 5,6
Use of intracardiac echocardiography to screen for atrial thrombi in patients
who cannot undergo TEE may be considered.
IIb C-EO 381–386
During ablation Heparin should be administered prior to or immediately following transseptal
puncture during AF catheter ablation procedures and adjusted to achieve
and maintain an ACT of at least 300 seconds.
I B-NR 369,380–382,387–393
Administration of protamine following AF catheter ablation to reverse heparin
is reasonable.
IIa B-NR 394
Postablation In patients who are not therapeutically anticoagulated prior to catheter abla-
tion of AF and in whom warfarin will be used for anticoagulation postabla-
tion, low molecular weight heparin or intravenous heparin should be used as
a bridge for initiation of systemic anticoagulation with warfarin following AF
ablation.*
I C-EO
Systemic anticoagulation with warfarin* or a NOAC is recommended for at
least 2 months postcatheter ablation of AF.
I C-EO 1,2
Adherence to AF anticoagulation guidelines is recommended for patients who
have undergone an AF ablation procedure, regardless of the apparent suc-
cess or failure of the procedure.
I C-EO 5,6
Decisions regarding continuation of systemic anticoagulation more than
2 months post ablation should be based on the patient’s stroke risk profile
and not on the perceived success or failure of the ablation procedure.
I C-EO 5,6
In patients who have not been anticoagulated prior to catheter ablation of AF
or in whom anticoagulation with a NOAC or warfarin has been interrupted
prior to ablation, administration of a NOAC 3 to 5 hours after achievement
of hemostasis is reasonable postablation.
IIa C-EO 372,376–380
Patients in whom discontinuation of anticoagulation is being considered based
on patient values and preferences should consider undergoing continuous
or frequent ECG monitoring to screen for AF recurrence.
IIb C-EO
AF, atrial fibrillation; LOE, Level of Evidence; NOAC, novel oral anticoagulant; TEE, transesophageal electrocardiogram; ACT, activated clotting time.
*Time in therapeutic range (TTR) should be > 65% – 70% on warfarin.
170 Guidelines
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Table 5 Signs and symptoms following AF ablation
Differential Suggested evaluation
Signs and symptoms of complications within a month postablation
Back pain Musculoskeletal, retroperitoneal hematoma Physical exam, CT imaging
Chest pain Pericarditis, pericardial effusion, coronary stenosis (ablation related), pul-
monary vein stenosis, musculoskeletal (after cardioversion), worsening
reflux
Physical exam, chest X-ray, ECG, echocardiogram, stress test,
cardiac catheterization, chest CT
Cough Infectious process, bronchial irritation (mechanical, cryoballoon), pulmon-
ary vein stenosis
Physical exam, chest X-ray, chest CT
Dysphagia Esophageal irritation (related to transesophageal echocardiography),
atrioesophageal fistula
Physical exam, chest CT or MRI
Early satiety, nausea Gastric denervation Physical exam, gastric emptying study
Fever Infectious process, pericarditis, atrioesophageal fistula Physical exam, chest X-ray, chest CT, urinalysis, laboratory
blood work
Fever, dysphagia, neuro-
logical symptoms
Atrial esophageal fistula Physical exam, laboratory blood work, chest CT or MRI; avoid
endoscopy with air insufflation
Groin pain at site of access Pseudoaneurysm, AV fistula, hematoma Ultrasound of the groin, laboratory blood work; consider CT
scan if ultrasound negative
Headache Migraine (related to anesthesia or transseptal access, hemorrhagic stroke),
effect of general anesthetic
Physical exam, brain imaging (MRI)
Hypotension Pericardial effusion/tamponade, bleeding, sepsis, persistent vagal reaction Echocardiography, laboratory blood work
Hemoptysis PV stenosis or occlusion, pneumonia Chest X-ray, chest CT or MR scan, VQ scan
Neurological symptoms Cerebral embolic event, atrial esophageal fistula Physical exam, brain imaging, chest CT or MRI
Shortness of breath Volume overload, pneumonia, pulmonary vein stenosis, phrenic nerve
injury
Physical exam, chest X-ray, chest CT, laboratory blood work
Signs and symptoms of complications more than a month postablation
Fever, dysphagia, neuro-
logical symptoms
Atrial esophageal fistula Physical exam, laboratory blood work, chest CT or MRI; avoid
endoscopy with air insufflation
Persistent cough, atypical
chest pain
Infectious process, pulmonary vein stenosis Physical exam, laboratory blood work, chest X-ray, chest CT
or MRI
Neurological symptoms Cerebral embolic event, atrial esophageal fistula Physical exam, brain imaging, chest CT or MRI
Hemoptysis PV stenosis or occlusion, pneumonia CT scan, VQ scan
AF, atrial fibrillation; ECG, electrocardiogram; CT, computed tomography; MRI, magnetic resonance imaging; VQ, ventilation-perfusion.
....................................................................................................................................................................................................................
Table 6 Types of ambulatory cardiac monitoring devices
Type of recorder Typical
monitoring
duration
Continuous
recording
Event
recording
Auto
trigger
Unique features
Holter monitor 24–48 hours,
approximately
7–30 days
Yes Yes N/A Short term, provides quantitative data on arrhythmia burden
Patch monitor 1–3 weeks Yes Yes N/A Intermediate term, can provide continuous data for up to several weeks; improved
patient compliance without lead wires
External loop
recorder
1 month Yes Yes Variable Good correlation between symptoms and even brief arrhythmias
External nonloop
recorder
Months No Yes No May be used long term and intermittently; will not capture very brief episodes
Smartphone monitor Indefinite No Yes No Provides inexpensive long-term intermittent monitoring; dependent on patient com-
pliance; requires a smartphone
Mobile cardiac
telemetry
30 days Yes Yes Yes Real time central monitoring and alarms; relatively expensive
Implantable loop
recorder
Up to 3 years Yes Yes Yes Improved patient compliance for long-term use; not able to detect 30-second epi-
sodes of AF due to detection algorithm; presence of AF needs to be confirmed
by EGM review because specificity of detection algorithm is imperfect; expensive
Pacemakers or ICDs
with atrial leads
Indefinite Yes Yes Yes Excellent AF documentation of burden and trends; presence of AF needs to be con-
firmed by electrogram tracing review because specificity of detection algorithms
is imperfect; expensive
Wearable
multisensor ECG
monitors
Indefinite Yes Yes Yes ECG 3 leads, temp, heart rate, HRV, activity tracking, respiratory rate, galvanic skin
response
AF, atrial fibrillation; ICD, implantable cardioverter defibrillator; ECG, electrocardiogram; HRV, heart rate variability.
Guidelines 171
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p
li
c
a
ti
o
n
s
C
o
m
m
e
n
ts
C
lin
ic
al
T
ri
al
s
Pe
rf
or
m
ed
fo
r
FD
A
A
pp
ro
va
l
JA
M
A
20
10
;3
03
:3
33
-
34
0
(T
he
rm
oC
oo
l
A
F)
1
4
20
10
R
an
do
m
iz
ed
to
R
F
ab
la
tio
n
or
A
A
D
,
m
ul
tic
en
te
r
16
7
Pa
ro
xy
sm
al
PV
I,
op
tio
na
l
C
FA
Es
an
d
lin
es
12
m
on
th
s
Fr
ee
do
m
fr
om
sy
m
p-
to
m
at
ic
pa
ro
xy
s-
m
al
at
ri
al
fib
ri
lla
tio
n,
ac
ut
e
pr
oc
ed
ur
al
fa
ilu
re
,
or
ch
an
ge
s
in
sp
ec
ifi
ed
dr
ug
re
gi
m
en
66
%
16
%
<
0.
00
1
4.
9%
8.
8%
FD
A
ap
pr
ov
al
re
ce
iv
ed
JA
C
C
20
13
;6
1:
17
13
-
17
23
(S
T
O
P
A
F)
9
20
13
R
an
do
m
iz
ed
to
cr
yo
-
ba
llo
on
ab
la
tio
n
or
A
A
D
,
m
ul
tic
en
te
r
24
5
Pa
ro
xy
sm
al
PV
I
12
m
on
th
s
Fr
ee
do
m
fr
om
an
y
de
te
ct
ab
le
A
F,
us
e
of
no
ns
tu
dy
A
A
D
,
or
no
np
ro
to
co
l
in
te
rv
en
tio
n
fo
r
A
F
70
%
7%
<
0.
00
1
3.
1%
N
A
FD
A
ap
pr
ov
al
re
ce
iv
ed
H
ea
rt
R
hy
th
m
20
14
;
11
:2
02
-2
09
(T
T
O
P)
2
2
20
14
R
an
do
m
iz
ed
to
ph
as
ed
R
F
ab
la
-
tio
n
or
A
A
D
/c
ar
-
di
ov
er
si
on
,
m
ul
tic
en
te
r
21
0
Pe
rs
is
te
nt
PV
Iþ
C
FA
Es
6
m
on
th
s
A
cu
te
pr
oc
ed
ur
al
su
cc
es
s,
>_
90
%
re
-
du
ct
io
n
in
A
F
bu
r-
de
n,
of
fA
A
D
56
%
26
%
<
0.
00
1
12
.3
%
N
A
N
ot
FD
A
ap
pr
ov
ed
JA
C
C
20
14
;6
4:
64
7-
65
6
(S
M
A
R
T
-A
F)
1
3
20
14
N
on
ra
nd
om
zi
ed
m
ul
tic
en
te
r
st
ud
y
of
co
nt
ac
t
fo
rc
e-
se
ns
in
g
R
F
ca
th
-
et
er
,c
om
pa
ri
ng
to
pe
rf
or
m
an
ce
go
al
s
17
2
Pa
ro
xy
sm
al
PV
I,
op
tio
na
l
C
FA
Es
an
d
lin
es
12
m
on
th
s
Fr
ee
do
m
fr
om
sy
m
p-
to
m
at
ic
A
F,
flu
t-
te
r,
ta
ch
yc
ar
di
a,
ac
ut
e
pr
oc
ed
ur
al
fa
ilu
re
,o
r
ch
an
ge
s
in
A
A
D
72
.5
%
N
/A
<
0.
00
01
7.
5%
N
A
FD
A
ap
pr
ov
al
re
ce
iv
ed
C
ir
cu
la
tio
n
20
15
;1
32
:
90
7-
91
5
(T
O
C
C
A
ST
A
R
)1
2
20
15
R
an
do
m
iz
ed
to
co
n-
ta
ct
fo
rc
e
se
ns
in
g
R
F
ca
th
et
er
or
ap
pr
ov
ed
R
F
ca
th
-
et
er
,m
ul
tic
en
te
r
30
0
Pa
ro
xy
sa
m
l
PV
I,
op
tio
na
l
tr
ig
ge
rs
,
C
A
FE
s
an
d
lin
es
in
bo
th
ar
m
s
12
m
on
th
s
A
cu
te
pr
oc
ed
ur
al
su
cc
es
s
þ
Fr
ee
do
m
fr
om
Sy
m
pt
om
at
ic
A
F/
Fl
ut
te
r/
T
ac
hy
ca
rd
ia
of
f
A
A
D
67
.8
%
69
.4
%
0.
00
73
fo
r
no
ni
nf
er
io
ri
ty
7.
2%
9.
1%
FD
A
ap
pr
ov
al
re
ce
iv
ed
JA
C
C
20
15
;6
6:
13
50
-
13
60
(H
ea
rt
Li
gh
t)
1
1
20
15
R
an
do
m
iz
ed
to
la
se
r-
ba
llo
on
or
ap
pr
ov
ed
R
F
ca
th
-
et
er
,m
ul
tic
en
te
r
35
3
Pa
ro
xy
sm
al
PV
I±
C
T
Ia
bl
a-
tio
n
vs
PV
I,
op
tio
na
l
C
FA
Es
,a
nd
Li
ne
s
12
m
on
th
s
Fr
ee
do
m
fr
om
Sy
m
pt
om
at
ic
A
F/
Fl
ut
te
r/
T
ac
hy
ca
rd
ia
,a
cu
te
pr
oc
ed
ur
al
fa
ilu
re
,
A
A
D
,o
r
no
n-
pr
o-
to
to
co
l
in
te
rv
en
tio
n
61
.1
%
61
.7
%
0.
00
3
fo
r
no
ni
nf
er
io
ri
ty
5.
3%
6.
4%
FD
A
ap
pr
ov
al
re
ce
iv
ed
Co
nt
in
ue
d
172 Guidelines
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T
ab
le
7
C
o
n
ti
n
u
e
d
T
ri
a
l
Y
e
a
r
T
y
p
e
N
A
F
ty
p
e
A
b
la
ti
o
n
st
ra
te
g
y
In
it
ia
l
ti
m
e
fr
a
m
e
E
ff
e
c
ti
v
e
n
e
ss
e
n
d
p
o
in
t
A
b
la
ti
o
n
su
c
c
e
ss
D
ru
g
/
C
o
n
tr
o
l
su
c
c
e
ss
P
v
a
lu
e
fo
r
su
c
c
e
ss
A
b
la
ti
o
n
c
o
m
p
li
c
a
ti
o
n
s
D
ru
g
/
C
o
n
tr
o
l
c
o
m
p
li
c
a
ti
o
n
s
C
o
m
m
e
n
ts
Fi
rs
t-
Li
ne
T
he
ra
py
T
ri
al
s
JA
M
A
20
05
;2
93
:
26
34
-2
64
0
(R
A
A
FT
)2
9
20
05
R
an
do
m
iz
ed
to
dr
ug
,
m
ul
tic
en
te
r
70
Pa
ro
xy
sm
al
(N
=
67
),
pe
r-
si
st
en
t
(N
=
3)
PV
I
12
m
on
th
s
Fr
ee
do
m
fr
om
de
-
te
ct
ab
le
A
F
84
%
37
%
<
0.
01
9%
11
%
N
EJ
M
20
12
;
36
7:
15
87
-1
59
5
(M
A
N
T
R
A
-P
A
F)
3
0
20
12
R
an
do
m
iz
ed
to
dr
ug
,
m
ul
tic
en
te
r
29
4
Pa
ro
xy
sm
al
A
F
PV
I,
ro
of
lin
e,
op
tio
na
lm
i-
tr
al
an
d
tr
i-
cu
sp
id
lin
e
24
m
on
th
s
C
um
ul
at
iv
e
A
F
bu
rd
en
13
%
A
F
bu
rd
en
19
%
A
F
bu
rd
en
N
S
17
%
15
%
JA
M
A
20
14
;3
11
:6
92
-
70
0
(R
A
A
FT
-2
)3
1
20
14
R
an
do
m
iz
ed
to
dr
ug
m
ul
tic
en
te
r
12
7
Pa
ro
xy
sm
al
A
F
PV
Ip
lu
s
op
tio
na
l
no
n-
PV
I
ta
rg
et
s
24
m
on
th
s
Fr
ee
do
m
fr
om
de
-
te
ct
ab
le
A
F,
flu
t-
te
r,
ta
ch
yc
ar
di
a
45
%
28
%
0.
02
9%
4.
9%
O
th
er
Pa
ro
xy
sm
al
A
F
A
bl
at
io
n
T
ri
al
s
JA
C
C
20
06
;4
8:
23
40
-
23
47
(A
PA
F)
1
6
20
06
R
an
do
m
iz
ed
to
dr
ug
si
ng
le
ce
nt
er
19
8
Pa
ro
xy
sm
al
A
F
PV
I,
m
itr
al
lin
e
an
d
tr
ic
us
pi
d
lin
e
12
m
on
th
s
Fr
ee
do
m
fr
om
de
-
te
ct
ab
le
A
F,
flu
t-
te
r,
ta
ch
yc
ar
di
a
86
%
22
%
<
0.
00
1
1%
23
%
C
ir
cu
la
tio
n
20
08
;1
18
:
24
98
-2
50
5
(A
4)
7
20
08
R
an
do
m
iz
ed
to
dr
ug
11
2
Pa
ro
xy
sm
al
PV
I(
op
tio
na
lL
A
lin
es
,C
T
I,
fo
ca
l)
12
m
on
th
s
Fr
ee
do
m
fr
om
A
F
89
%
23
%
<
0.
00
01
5.
7%
1.
7%
N
EJ
M
20
16
;3
74
:
22
35
-2
24
5
(F
IR
E
A
N
D
IC
E)
1
0
20
16
R
an
do
m
iz
ed
R
F
vs
C
ry
o,
m
ul
tic
en
te
r
76
2
Pa
ro
xy
sm
al
A
F
PV
I
12
m
on
th
s
Fr
ee
do
m
fr
om
de
-
te
ct
ab
le
A
F,
flu
t-
te
r,
ta
ch
yc
ar
di
a
64
.1
%
(R
F)
65
.4
%
(c
ry
o)
N
S
12
.8
%
10
.2
%
JA
C
C
20
16
;6
8:
27
47
-
27
57
1
5
20
16
R
an
do
m
iz
ed
to
ho
t
ba
llo
on
or
dr
ug
,
m
ul
tic
en
te
r
10
0
Pa
ro
xy
sm
al
A
F
PV
I
12
m
on
th
s
Fr
ee
do
m
fr
om
A
F
59
%
5%
<
0.
00
1
10
.4
%
4.
7%
O
th
er
Pe
rs
is
te
nt
A
F
A
bl
at
io
n
T
ri
al
s
N
EJ
M
20
06
;3
54
:9
34
-
94
12
5
20
06
R
an
do
m
iz
ed
to
R
F
ab
la
tio
n
or
to
C
V
an
d
sh
or
t
te
rm
am
io
14
6
Pe
rs
is
te
nt
PV
I,
ro
of
,m
itr
al
lin
e
12
m
on
th
s
N
o
A
F
or
flu
tt
er
m
on
th
12
74
%
58
%
0.
05
1.
3%
1.
4%
EH
J2
01
4;
35
:5
01
-5
07
(S
A
R
A
)2
6
20
14
R
an
do
m
iz
ed
to
dr
ug
(2
:1
ab
la
tio
n
to
dr
ug
),
m
ul
tic
en
te
r
14
6
Pe
rs
is
te
nt
PV
I(
op
tio
na
lL
A
lin
es
,C
FA
Es
)
12
m
on
th
s
Fr
ee
do
m
fr
om
A
F/
flu
tt
er
la
st
in
g
>
24
h
70
%
44
%
0.
00
2
6.
1%
4.
20
%
N
EJ
M
20
15
;3
72
:
18
12
-1
82
21
9
20
15
R
an
do
m
iz
ed
ab
la
tio
n
st
ra
te
gi
es
,
m
ul
tic
en
te
r
58
9
Pe
rs
is
te
nt
PV
Ia
lo
ne
ve
rs
us
PV
I&
C
FA
Es
or
PV
I&
lin
es
18
m
on
th
s
Fr
ee
do
m
fr
om
afi
b
w
ith
or
w
ith
ou
t
dr
ug
s
59
%
(P
V
Ia
lo
ne
)
49
%
&
46
%
N
S
6%
4.
3%
&
7.
6%
O
th
er
M
ix
ed
Pa
ro
xy
sm
al
an
d
Pe
rs
is
te
nt
A
F
A
bl
at
io
n
T
ri
al
s
JM
ed
A
ss
oc
T
ha
i
20
03
;8
6
(S
up
pl
1)
:
S8
-S
16
2
4
20
03
R
an
do
m
iz
ed
to
R
F
ab
la
tio
n
or
am
io
da
ro
ne
30
Pa
ro
xy
sm
al
(7
0%
),
Pe
rs
is
te
nt
(3
0%
)
PV
I,
m
itr
al
lin
e,
C
T
I,
SV
C
to
IV
C
12
m
on
th
s
Fr
ee
do
m
fr
om
A
F
79
%
40
%
0.
01
8
6.
70
%
47
%
Co
nt
in
ue
d
Guidelines 173
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by CNIC Fundación Centro Nacional de Investigaciones Cardiovasculares user
on 16 April 2018
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T
ab
le
7
C
o
n
ti
n
u
e
d
T
ri
a
l
Y
e
a
r
T
y
p
e
N
A
F
ty
p
e
A
b
la
ti
o
n
st
ra
te
g
y
In
it
ia
l
ti
m
e
fr
a
m
e
E
ff
e
c
ti
v
e
n
e
ss
e
n
d
p
o
in
t
A
b
la
ti
o
n
su
c
c
e
ss
D
ru
g
/
C
o
n
tr
o
l
su
c
c
e
ss
P
v
a
lu
e
fo
r
su
c
c
e
ss
A
b
la
ti
o
n
c
o
m
p
li
c
a
ti
o
n
s
D
ru
g
/
C
o
n
tr
o
l
c
o
m
p
li
c
a
ti
o
n
s
C
o
m
m
e
n
ts
EH
J2
00
6;
27
:
21
6-
22
11
7
20
06
R
an
do
m
iz
ed
to
R
F
ab
la
tio
n
or
dr
ug
,
m
ul
tic
en
te
r
13
7
Pa
ro
xy
sm
al
(6
7%
),
Pe
rs
is
te
nt
(3
3%
)
PV
I,
m
itr
al
lin
e,
C
T
I
12
m
on
th
s
Fr
ee
do
m
fr
om
A
F,
flu
tt
er
,
ta
ch
yc
ar
di
a
66
%
9%
<
0.
00
1
4.
40
%
2.
90
%
JC
V
EP
20
09
,2
0:
22
-2
81
8
20
09
R
an
do
m
iz
ed
to
R
F
ab
la
tio
n
or
dr
ug
,
m
ul
tic
en
te
r
70
Pa
ro
xy
sm
al
(4
1%
),
Pe
rs
is
te
nt
(5
9%
)
&
ty
pe
2
D
M
PV
I,
C
T
I,
op
-
tio
na
lm
itr
al
lin
e
an
d
ro
of
lin
e
12
m
on
th
s
Fr
ee
do
m
fr
om
A
F
an
d
at
yp
ic
al
at
ri
al
flu
tt
er
80
%
43
%
0.
00
1
2.
90
%
17
%
R
an
do
m
iz
ed
T
ri
al
s
of
A
F
A
bl
at
io
n
in
Pa
tie
nt
s
w
ith
H
ea
rt
Fa
ilu
re
N
EJ
M
20
08
;3
59
:
17
78
-1
78
5
(P
A
BA
-H
F)
3
8
20
08
R
an
do
m
iz
ed
to
R
F
ab
la
tio
n
of
A
V
Ja
bl
an
d
Bi
V
pa
ci
ng
81
Pe
rs
is
te
nt
(5
0%
),
Pa
ro
xy
sm
al
(5
0%
),
EF
27
%
ab
l,
29
%
A
V
J
PV
I,
op
tio
na
ll
in
-
ea
r
ab
la
nd
C
FA
Es
6
m
on
th
s
C
om
po
si
te
EF
,6
m
in
w
al
k,
M
LW
H
F
sc
or
e;
fr
ee
do
m
fr
om
A
F
(s
ec
on
d-
ar
y,
m
ul
t
pr
oc
,
þ/
-
A
A
dr
ug
s)
88
%
A
F
fr
ee
,E
F
35
%
ab
l,
28
%
A
V
J(
P
<
.0
01
),
>
Q
O
L
an
d
6
m
in
w
al
k
in
-
cr
ea
se
w
ith
ab
l
<
0.
00
1
14
.6
0%
17
.5
0%
H
ea
rt
20
11
;9
7:
74
0-
74
73
9
20
11
R
an
do
m
iz
ed
to
R
F
ab
la
tio
n
or
ph
ar
m
ac
ol
og
ic
al
ra
te
co
nt
ro
l
41
Pe
rs
is
te
nt
,E
F
20
%
ab
l,
16
%
ra
te
co
nt
ro
l
PV
I,
ro
of
lin
e,
C
FA
Es
6
m
on
th
s
C
ha
ng
e
in
LV
EF
,
si
nu
s
rh
yt
hm
at
6
m
on
th
s
(s
ec
on
da
ry
)
50
%
in
N
SR
,
LV
EF
in
cr
ea
se
4.
5%
0%
in
N
SR
,
LV
EF
in
cr
ea
se
2.
8%
0.
6
(f
or
EF
in
cr
ea
se
)
15
%
N
ot
re
po
rt
ed
JA
C
C
20
13
;6
1:
18
94
-1
90
34
6
20
13
R
an
do
m
iz
ed
to
R
F
ab
la
tio
n
or
ph
ar
m
ac
ol
og
ic
al
ra
te
co
nt
ro
l
52
Pe
rs
is
te
nt
A
F
(1
00
%
),
EF
22
%
ab
l,
25
%
ra
te
co
nt
ro
l
PV
I,
op
tio
na
ll
in
-
ea
r
ab
la
nd
C
FA
Es
12
m
on
th
s
C
ha
ng
e
in
pe
ak
O
2
co
ns
um
pt
io
n
(a
ls
o
re
po
rt
ed
si
ng
le
pr
oc
ed
ur
e
of
f
dr
ug
ab
la
tio
n
su
cc
es
s)
Pe
ak
O
2
co
n-
su
m
pt
io
n
in
-
cr
ea
se
gr
ea
te
r
w
ith
ab
l,
72
%
ab
ls
uc
ce
ss
0.
01
8
15
%
N
ot
re
po
rt
ed
C
ir
c
A
an
d
E
20
14
;
7:
31
-3
84
0
20
14
R
an
do
m
iz
ed
to
R
F
ab
la
tio
n
or
ph
ar
m
ac
ol
og
ic
al
ra
te
co
nt
ro
l
50
Pe
rs
is
te
nt
A
F
(1
00
%
),
EF
32
%
ab
l,
34
%
ra
te
co
nt
ro
l
PV
I,
op
tio
na
ll
in
-
ea
r
ab
la
nd
C
FA
Es
6
m
on
th
s
C
ha
ng
e
in
LV
EF
at
6
m
on
th
s,
m
ul
tip
le
pr
oc
ed
ur
e
fr
ee
-
do
m
fr
om
A
F
al
so
re
po
rt
ed
LV
EF
40
%
w
ith
ab
l,
31
%
ra
te
co
nt
ro
l,
81
%
A
F
fr
ee
w
ith
ab
l
0.
01
5
7.
70
%
A
F,
at
ri
al
fib
ri
lla
tio
n;
R
F,
ra
di
of
re
qu
en
cy
;A
V
J,
at
ri
ov
en
tr
ic
ul
ar
ju
nc
tio
n;
ab
l,
ab
la
tio
n;
Bi
V
,b
iv
en
tr
ic
ul
ar
;E
F,
ej
ec
tio
n
fr
ac
tio
n;
PV
I,
pu
lm
on
ar
y
ve
in
is
ol
at
io
n;
C
FA
Es
,c
om
pl
ex
fr
ac
tio
na
te
d
at
ri
al
el
ec
tr
og
ra
m
s;
M
LW
H
F,
M
in
ne
so
ta
Li
vi
ng
w
ith
H
ea
rt
Fa
ilu
re
;
LV
EF
,l
ef
t
ve
nt
ri
cu
la
r
ej
ec
tio
n
fr
ac
tio
n;
Q
O
L,
qu
al
ity
of
lif
e;
N
SR
,n
or
m
al
si
nu
s
rh
yt
hm
.
174 Guidelines
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Table 8 Definitions of complications associated with AF ablation
Asymptomatic cerebral
embolism
Asymptomatic cerebral embolism is defined as an occlusion of a blood vessel in the brain due to an embolus that does
not result in any acute clinical symptoms. Silent cerebral embolism is generally detected using a diffusion weighted
MRI.
Atrioesophageal fistula An atrioesophageal fistula is defined as a connection between the atrium and the lumen of the esophagus. Evidence sup-
porting this diagnosis includes documentation of esophageal erosion combined with evidence of a fistulous connec-
tion to the atrium, such as air emboli, an embolic event, or direct observation at the time of surgical repair. A CT
scan or MRI scan is the most common method of documentation of an atrioesophageal fistula.
Bleeding Bleeding is defined as a major complication of AF ablation if it requires and/or is treated with transfusion or results in a
20% or greater fall in hematocrit.
Bleeding following cardiac
surgery
Excessive bleeding following a surgical AF ablation procedure is defined as bleeding requiring reoperation or >_ 2 units
of PRBC transfusion within any 24 hours of the first 7 days following the index procedure.
Cardiac perforation We recommend that cardiac perforation be defined together with cardiac tamponade. See “Cardiac tamponade/
perforation.”
Cardiac tamponade We recommend that cardiac tamponade be defined together with cardiac perforation. See “Cardiac tamponade/
perforation.”
Cardiac tamponade/
perforation
Cardiac tamponade/perforation is defined as the development of a significant pericardial effusion during or within 30
days of undergoing an AF ablation procedure. A significant pericardial effusion is one that results in hemodynamic
compromise, requires elective or urgent pericardiocentesis, or results in a 1-cm or more pericardial effusion as docu-
mented by echocardiography. Cardiac tamponade/perforation should also be classified as “early” or “late” depending
on whether it is diagnosed during or following initial discharge from the hospital.
Deep sternal wound infec-
tion/mediastinitis following
cardiac surgery
Deep sternal wound infection/mediastinitis following cardiac surgery requires one of the following: (1) an organism iso-
lated from culture of mediastinal tissue or fluid; (2) evidence of mediastinitis observed during surgery; (3) one of the
following conditions: chest pain, sternal instability, or fever (>38 C), in combination with either purulent discharge
from the mediastinum or an organism isolated from blood culture or culture of mediastinal drainage.
Esophageal injury Esophageal injury is defined as an erosion, ulceration, or perforation of the esophagus. The method of screening for
esophageal injury should be specified. Esophageal injury can be a mild complication (erosion or ulceration) or a major
complication (perforation).
Gastric motility/pyloric
spasm disorders
Gastric motility/pyloric spasm disorder should be considered a major complication of AF ablation when it prolongs or
requires hospitalization, requires intervention, or results in late disability, such as weight loss, early satiety, diarrhea,
or GI disturbance.
Major complication A major complication is a complication that results in permanent injury or death, requires intervention for treatment,
or prolongs or requires hospitalization for more than 48 hours. Because early recurrences of AF/AFL/AT are to be
expected following AF ablation, recurrent AF/AFL/AT within 3 months that requires or prolongs a patient’s hospital-
ization should not be considered to be a major complication of AF ablation.
Mediastinitis Mediastinitis is defined as inflammation of the mediastinum. Diagnosis requires one of the following: (1) an organism iso-
lated from culture of mediastinal tissue or fluid; (2) evidence of mediastinitis observed during surgery; (3) one of the
following conditions: chest pain, sternal instability, or fever (>38 C), in combination with either purulent discharge
from the mediastinum or an organism isolated from blood culture or culture of mediastinal drainage.
Myocardial infarction in the
context of AF ablation
The universal definition of myocardial infarction395 cannot be applied in the context of catheter or surgical AF ablation
procedures because it relies heavily on cardiac biomarkers (troponin and CPK), which are anticipated to increase in
all patients who undergo AF ablation as a result of the ablation of myocardial tissue. Similarly, chest pain and other
cardiac symptoms are difficult to interpret in the context of AF ablation both because of the required sedation and
anesthesia and also because most patients experience chest pain following the procedure as a result of the associated
pericarditis that occurs following catheter ablation. We therefore propose that a myocardial infarction, in the con-
text of catheter or surgical ablation, be defined as the presence of any one of the following criteria: (1) detection of
ECG changes indicative of new ischemia (new ST-T wave changes or new LBBB) that persist for more than 1 hour;
(2) development of new pathological Q waves on an ECG; (3) imaging evidence of new loss of viable myocardium or
new regional wall motion abnormality.
Pericarditis Pericarditis should be considered a major complication following ablation if it results in an effusion that leads to hemo-
dynamic compromise or requires pericardiocentesis, prolongs hospitalization by more than 48 hours, requires hospi-
talization, or persists for more than 30 days following the ablation procedure.
Phrenic nerve paralysis Phrenic nerve paralysis is defined as absent phrenic nerve function as assessed by a sniff test. A phrenic nerve paralysis
is considered to be permanent when it is documented to be present 12 months or longer following ablation.
Continued
Guidelines 175
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recurrence based on ECG monitoring. Arrhythmia monitoring can
be performed with the use of noncontinuous or continuous ECG
monitoring tools (Table 6). This section also discusses the important
topics of AAD and non-AAD use prior to and following AF ablation,
the role of cardioversion, as well as the indications for and timing of
repeat AF ablation procedures.
Section 9: Outcomes and Efficacy
This section provides a comprehensive review of the outcomes of
catheter ablation of AF. Table 7 summarizes the main findings of the
most important clinical trials in this field. Outcomes of AF ablation in
subsets of patients not well represented in these trials are reviewed.
Outcomes for specific ablation systems and strategies (CB ablation, ro-
tational activity ablation, and laser balloon ablation) are also reviewed.
Section 10: Complications
Catheter ablation of AF is one of the most complex interventional
electrophysiological procedures. AF ablation by its nature involves
catheter manipulation and ablation in the delicate thin-walled atria,
which are in close proximity to other important organs and struc-
tures that can be impacted through collateral damage. It is therefore
not surprising that AF ablation is associated with a significant risk of
complications, some of which might result in life-long disability and/
or death. This section reviews the complications associated with
catheter ablation procedures performed to treat AF. The types and
incidence of complications are presented, their mechanisms are
explored, and the optimal approach to prevention and treatment is
discussed (Tables 8 and 9).
Pulmonary vein stenosis Pulmonary vein stenosis is defined as a reduction of the diameter of a PV or PV branch. PV stenosis can be categorized
as mild <50%, moderate 50%–70%, and severe >_70% reduction in the diameter of the PV or PV branch. A severe PV
stenosis should be considered a major complication of AF ablation.
Serious adverse device effect A serious adverse device effect is defined as a serious adverse event that is attributed to use of a particular device.
Stiff left atrial syndrome Stiff left atrial syndrome is a clinical syndrome defined by the presence of signs of right heart failure in the presence of
preserved LV function, pulmonary hypertension (mean PA pressure >25 mm Hg or during exercise >30 mm Hg), and
large V waves >_10 mm Hg or higher) on PCWP or left atrial pressure tracings in the absence of significant mitral
valve disease or PV stenosis.
Stroke or TIA postablation Stroke diagnostic criteria
• Rapid onset of a focal or global neurological deficit with at least one of the following: change in level of consciousness,
hemiplegia, hemiparesis, numbness or sensory loss affecting one side of the body, dysphasia or aphasia, hemianopia,
amaurosis fugax, or other neurological signs or symptoms consistent with stroke
• Duration of a focal or global neurological deficit >_24 hours; OR < 24 hours if therapeutic intervention(s) were per-
formed (e.g., thrombolytic therapy or intracranial angioplasty); OR available neuroimaging documents a new hemor-
rhage or infarct; OR the neurological deficit results in death.
• No other readily identifiable nonstroke cause for the clinical presentation (e.g., brain tumor, trauma, infection, hypo-
glycemia, peripheral lesion, pharmacological influences).*
• Confirmation of the diagnosis by at least one of the following: neurology or neurosurgical specialist; neuroimaging
procedure (MRI or CT scan or cerebral angiography); lumbar puncture (i.e., spinal fluid analysis diagnostic of intracra-
nial hemorrhage)
Stroke definitions
• Transient ischemic attack: new focal neurological deficit with rapid symptom resolution (usually 1 to 2 hours), always
within 24 hours; neuroimaging without tissue injury
• Stroke: (diagnosis as above, preferably with positive neuroimaging study);
Minor—Modified Rankin score <2 at 30 and 90 days†
Major—Modified Rankin score >_2 at 30 and 90 days
Unanticipated adverse de-
vice effect
Unanticipated adverse device effect is defined as complication of an ablation procedure that has not been previously
known to be associated with catheter or surgical ablation procedures.
Vagal nerve injury Vagal nerve injury is defined as injury to the vagal nerve that results in esophageal dysmotility or gastroparesis. Vagal
nerve injury is considered to be a major complication if it prolongs hospitalization, requires hospitalization, or results
in ongoing symptoms for more than 30 days following an ablation procedure.
Vascular access complication Vascular access complications include development of a hematoma, an AV fistula, or a pseudoaneurysm. A major vascu-
lar complication is defined as one that requires intervention, such as surgical repair or transfusion, prolongs the hos-
pital stay, or requires hospital admission.
AF, atrial fibrillation; CT, computed tomography; MRI, magnetic resonance imaging; PRBC, packed red blood cell; AFL, atrial flutter; AT, atrial tachycardia; CPK, creatine phos-
phokinase; ECG, electrocardiogram; LBBB, left bundle branch block.
*Patients with nonfocal global encephalopathy will not be reported as a stroke without unequivocal evidence based on neuroimaging studies.
†
Modified Rankin score assessments should be made by qualified individuals according to a certification process. If there is discordance between the 30- and 90-day modified
Rankin scores, a final determination of major versus minor stroke will be adjudicated by the neurology members of the clinical events committee.
176 Guidelines
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....................................................................................................................................................................................................................
Table 9 Incidence, prevention, diagnosis, and treatment of selected complications of AF ablation
Complication Incidence Selected prevention
techniques
Diagnostic testing Selected treat-
ment options
References
Air embolism <1% Sheath management Nothing or cardiac
catheterization
Supportive care with
fluid, oxygen, head
down tilt, hyper-
baric oxygen
388,396–401
Asymptomatic cere-
bral emboli (ACE)
2% to 15% Anticoagulation, catheter and
sheath management, TEE
Brain MRI None 402–419
Atrial esophageal
fistula
0.02% to 0.11% Reduce power, force, and RF
time on posterior wall, moni-
tor esophageal temp, use
proton pump inhibitors; avoid
energy delivery over
esophagus
CT scan of chest, MRI;
avoid endoscopy
with air insufflation
Surgical repair 337–365,420–456
Cardiac tamponade 0.2% to 5% Cather manipulation, transsep-
tal technique, reduce power,
force, and RF time
Echocardiography Pericardiocentesis or
surgical drainage
338,343,347,457–467
Coronary artery
stenosis/occlusion
<0.1% Avoid high-power energy deliv-
ery near coronary arteries
Cardiac
catheterization
PTCA 468–476
Death <0.1% to 0.4% Meticulous performance of pro-
cedure, attentive postproce-
dure care
NA NA 338,343,347,458,477
Gastric hypomotility 0% to 17% Reduce power, force, and RF
time on posterior wall
Endoscopy, barium
swallow, gastric
emptying study
Metoclopramide, pos-
sibly intravenous
erythromycin
478–490
Mitral valve
entrapment
<0.1% Avoid circular catheter place-
ment near or across mitral
valve; clockwise torque on
catheter
Echocardiography Gentle catheter ma-
nipulation, surgical
extraction
491–498
Pericarditis 0% to 50% None proven Clinical history, ECG,
sedimentation rate,
echocardiogram
NSAID, colchicine,
steroids
499–506
Permanent phrenic
nerve paralysis
0% to 0.4% Monitor diaphragm during
phrenic pacing, CMAP moni-
toring, phrenic pacing to
identify location and adjust le-
sion location
CXR, sniff test Supportive care 9,11,156,347,367,446,
457,478,479,487–
490,507–528
Pulmonary vein
stenosis
<1% Avoid energy delivery within PV CT or MRI, V/Q wave
scan
Angioplasty, stent,
surgery
9,11,313,316–335,
457,529–531
Radiation injury <0.1% Minimize fluoroscopy exposure,
especially in obese and repeat
ablation patients, X-ray
equipment
None Supportive care,
rarely skin graft
513,532–550
Stiff left atrial
syndrome
<1.5% Limit extent of left atrial
ablation
Echocardiography,
cardiac
catheterization
Diuretics 551–558
Stroke and TIA 0% to 2% Pre-, post-, and intraprocedure
anticoagulation, catheter and
sheath management, TEE
Head CT or MRI,
cerebral
angiography
Thrombolytic therapy,
angioplasty
10–13,338,347,367,
458,559–565
Vascular
complications
0.2% to 1.5% Vascular access techniques,
ultrasound-guided access,
anticoagulation management
Vascular ultrasound,
CT scan
Conservative treat-
ment, surgical re-
pair, transfusion
338,347,371,373,374,
380,458,511,566–
575
AF, atrial fibrillation; CT, computed tomography; MRI, magnetic resonance imaging; TEE, transesophageal electrocardiogram; RF, radiofrequency; PTCA, percutaneous translu-
minal coronary angioplasty; NA, not applicable; ECG, electrocardiogram; NSAID, nonsteroidal anti-inflammatory drug; CMAP, compound motor action potentials; CXR, chest
X-ray; TIA, transient ischemic attack.
Guidelines 177
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Table 10 Definitions for use when reporting outcomes of AF ablation and in designing clinical trials of catheter or
surgical ablation of AF
Acute procedural success
(pulmonary vein isolation)
Acute procedural success is defined as electrical isolation of all pulmonary veins. A minimal assessment of electrical
isolation of the PVs should consist of an assessment of entrance block. If other methods are used to assess PVI,
including exit block and/or the use of provocative agents such as adenosine or isoproterenol, they should be pre-
specified. Furthermore, it is recommended that the wait time used to screen for early recurrence of PV conduc-
tion once initial electrical isolation is documented be specified in all prospective clinical trials.
Acute procedural success
(not related by pulmonary
vein isolation)
Typically, this would apply to substrate ablation performed in addition to PVI for persistent AF. Although some
have proposed AF termination as a surrogate for acute procedural success, its relationship to long-term success
is controversial. Complete elimination of the additional substrate (localized rotational activation, scar region,
non-PV trigger, or other target) and/or demonstration of bidirectional conduction block across a linear ablation
lesion would typically be considered the appropriate endpoint.
One-year success* One-year success is defined as freedom from AF/AFL/AT after removal from antiarrhythmic drug therapy as as-
sessed from the end of the 3month blanking period to 12 months following the ablation procedure. Because cav-
otricuspid isthmus-dependent atrial flutter is easily treated with cavotricuspid isthmus ablation and is not an
iatrogenic arrhythmia following a left atrial ablation procedure for AF, it is reasonable for clinical trials to choose
to prespecify that occurrence of isthmus-dependent atrial flutter, if confirmed by entrainment maneuvers during
electrophysiology testing, should not be considered an ablation failure or primary effectiveness endpoint.
Alternative one-year success Although the one-year success definition provided above remains the recommended end point that should be re-
ported in all AF ablation trials, and the endpoint for which the objective performance criteria listed below were
developed, the Task Force recognizes that alternative definitions for success can be used if the main goal of ther-
apy in the study is to relieve AF-related symptoms and to improve patient QOL. In particular, it is appropriate
for clinical trials to define success as freedom from only symptomatic AF/AFL/AT after removal from antiarrhyth-
mic drug therapy as assessed from the end of the 3-month blanking period to 12 months following the ablation
procedure if the main goal of therapy in the study is to relieve AF-related symptoms and to improve patient
QOL. However, because symptoms of AF can resolve over time, and because studies have shown that asymp-
tomatic AF represents a greater proportion of all AF postablation than prior to ablation, clinical trials need to
continue to report freedom from both symptomatic and asymptomatic AF even if this alternative one year suc-
cess definition is used as the primary trial endpoint.
Clinical/partial success* It is reasonable for clinical trials to define and incorporate one or more secondary definitions of success that can be
referred to as “clinical success” or “partial success.” If these alternative definitions of success are included, they
should be defined prospectively. In prior Consensus Documents the Task Force has proposed that clinical/partial
success be defined as a “75% or greater reduction in the number of AF episodes, the duration of AF episodes, or
the % time a patient is in AF as assessed with a device capable of measuring AF burden in the presence or ab-
sence of previously ineffective antiarrhythmic drug therapy.” Because there is no firm scientific basis for selecting
the cutoff of 75% rather than a different cutoff, this prior recommendation is provided only as an example of
what future clinical trials may choose to use as a definition of clinical/partial success.
Long-term success* Long-term success is defined as freedom from AF/AFL/AT recurrences following the 3-month blanking period
through a minimum of 36-month follow-up from the date of the ablation procedure in the absence of Class I and
III antiarrhythmic drug therapy.
Recurrent AF/AFL/AT Recurrent AF/AFL/AT is defined as AF/AFL/AT of at least 30 seconds’ duration that is documented by an ECG or
device recording system and occurs following catheter ablation. Recurrent AF/AFL/AT may occur within or fol-
lowing the post ablation blanking period. Recurrent AF/AFL/AT that occurs within the postablation blanking
period is not considered a failure of AF ablation.
Early recurrence of
AF/AFL/AT
Early recurrence of AF/AFL/AT is defined as a recurrence of atrial fibrillation within three months of ablation.
Episodes of atrial tachycardia or atrial flutter should also be classified as a “recurrence.” These are not counted
toward the success rate if a blanking period is specified.
Recurrence of AF/AFL/AT Recurrence of AF/AFL/AT postablation is defined as a recurrence of atrial fibrillation more than 3 months following
AF ablation. Episodes of atrial tachycardia or atrial flutter should also be classified as a “recurrence.”
Late recurrence of AF/
AFL/AT
Late recurrence of AF/AFL/AT is defined as a recurrence of atrial fibrillation 12 months or more after AF ablation.
Episodes of atrial tachycardia or atrial flutter should also be classified as a “recurrence.”
Blanking period A blanking period of three months should be employed after ablation when reporting efficacy outcomes. Thus, early
recurrences of AF/AFL/AT within the first 3 months should not be classified as treatment failure. If a blanking
period of less than 3 months is chosen, it should be prespecified and included in the Methods section.
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Stroke screening A risk-based approach to determine the level of postablation stroke screening in clinical trials is recommended by
the Task Force. For ablation devices with a lower risk of stroke and for which a stroke signal has not been re-
ported, a minimum standardized neurological assessment of stroke should be conducted by a physician at base-
line and at hospital discharge or 24 hours after the procedure, whichever is later. If this neurological assessment
demonstrates new abnormal findings, the patient should have a formal neurological consult and examination with
appropriate imaging (i.e., DW-MRI), used to confirm any suspected diagnosis of stroke. For devices in which a
higher risk of stroke is suspected or revealed in prior trials, a formal neurological examination by a neurologist at
discharge or 24 hours after the procedure, whichever is later, is recommended. Appropriate imaging should be
obtained if this evaluation reveals a new neurological finding. In some studies in which delayed stroke is a con-
cern, repeat neurological screening at 30 days postablation might be appropriate.
Detectable AF/AFL/AT Detectable AF is defined as AF/AFL/AT of at least 30 seconds’ duration when assessed with ECG monitoring. If
other monitoring systems are used, including implantable pacemakers, implantable defibrillators, and subcutane-
ous ECG monitoring devices, the definition of detectable AF needs to be prespecified in the clinical trial based on
the sensitivity and specificity of AF detection with the particular device. We recommend that episodes of atrial
flutter and atrial tachycardia be included within the broader definition of a detectable AF/AFL/AT episode.
AF/AFL/AT burden It is reasonable for clinical trials to incorporate AF/AFL/AT burden as a secondary endpoint in a clinical trial of AF
ablation. In stating this it is recognized that there are no conclusive data that have validated a rate of AF burden
reduction as a predictor of patient benefit (i.e. reduction in mortality and major morbidities such as stroke, CHF,
QOL, or hospitalization). If AF burden is included, it is important to predefine and standardize the monitoring
technique that will be used to measure AF burden. Available monitoring techniques have been discussed in this
document. Should AF burden be selected as an endpoint in a clinical trial, the chosen monitoring technique
should be employed at least a month prior to ablation to establish a baseline burden of AF.
Entrance block Entrance block is defined as the absence, or if present, the dissociation, of electrical activity within the PV antrum.
Entrance block is most commonly evaluated using a circular multielectrode mapping catheter positioned at the
PV antrum. Entrance block can also be assessed using detailed point-by-point mapping of the PV antrum guided
by an electroanatomical mapping system. The particular method used to assess entrance block should be speci-
fied in all clinical trials. Entrance block of the left PVs should be assessed during distal coronary sinus or left atrial
appendage pacing in order to distinguish far-field atrial potentials from PV potentials. It is recommended that re-
assessment of entrance block be performed a minimum of 20 minutes after initial establishment of PV isolation.
Procedural endpoints for AF
ablation strategies not tar-
geting the PVs
Procedural endpoints for AF ablation strategies not targeting the PVs: The acute procedural endpoints for ablation
strategies not targeting the PVs vary depending on the specific ablation strategy and tool. It is important that they
be prespecified in all clinical trials. For example, if a linear ablation strategy is used, documentation of bidirectional
block across the ablation line must be shown. For ablation of CFAEs, rotational activity, or non-PV triggers, the
acute endpoint should at a minimum be elimination of CFAEs, rotational activity, or non-PV triggers.
Demonstration of AF slowing or termination is an appropriate procedural endpoint, but it is not required as a
procedural endpoint for AF ablation strategies not targeting the PVs.
Esophageal temperature
monitoring
Esophageal temperature monitoring should be performed in all clinical trials of AF ablation. At a minimum, a single
thermocouple should be used. The location of the probe should be adjusted during the procedure to reflect the
location of energy delivery. Although this document does not provide formal recommendations regarding the
specific temperature or temperature change at which energy delivery should be terminated, the Task Force does
recommend that all trials prespecify temperature guidelines for termination of energy delivery.
Enrolled subject An enrolled subject is defined as a subject who has signed written informed consent to participate in the trial in
question.
Exit block Exit block is defined as the inability to capture the atrium during pacing at multiple sites within the PV antrum. Local
capture of musculature within the pulmonary veins and/or antrum must be documented to be present to make
this assessment. Exit block is demonstrated by a dissociated spontaneous pulmonary vein rhythm.
Nonablative strategies The optimal nonablative therapy for patients with persistent and long-standing persistent AF who are randomized
to the control arm of an AF ablation trial is a trial of a new Class I or III antiarrhythmic agent or a higher dose of a
previously failed antiarrhythmic agent. For patients with persistent or long-standing persistent AF, performance
of a direct-current cardioversion while taking the new or dose adjusted antiarrhythmic agent should be per-
formed, if restoration of sinus rhythm is not achieved following initiation and/or dose adjustment of antiarrhyth-
mic drug therapy. Failure of pharmacological cardioversion alone is not adequate to declare this pharmacological
strategy unsuccessful.
Noninducibility of atrial
fibrillation
Noninducibility of atrial fibrillation is defined as the inability to induce atrial fibrillation with a standardized prespeci-
fied pharmacological or electrical stimulation protocol. The stimulation protocol should be prespecified in the
specific clinical trial. Common stimulation approaches include a high-dose isoproterenol infusion protocol or re-
peated atrial burst pacing at progressively more rapid rates.
Continued
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Patient populations for inclu-
sion in clinical trials
It is considered optimal for clinical trials to enroll patients with only one type of AF: paroxysmal, persistent, or long-
standing persistent. If more than one type of AF patient is enrolled, the results of the trial should also be reported
separately for each of the AF types. It is recognized that “early persistent” AF responds to AF ablation to a similar
degree as patients with paroxysmal AF and that the response of patients with “late persistent AF” is more similar
to that in those with long-standing persistent AF.
Therapy consolidation
period
Following a 3-month blanking period, it is reasonable for clinical trials to incorporate an additional 1- to 3-month
therapy consolidation period. During this time, adjustment of antiarrhythmic medications and/or cardioversion
can be performed. Should a consolidation period be incorporated into a clinical trial design, the minimum follow-
up duration should be 9 months following the therapy consolidation period. Performance of a repeat ablation
procedure during the blanking or therapy consolidation period would “reset” the endpoint of the study and trig-
ger a new 3-month blanking period. Incorporation of a therapy consolidation period can be especially appropriate
for clinical trials evaluating the efficacy of AF ablation for persistent or long-standing persistent AF. The challenge
of this approach is that it prolongs the overall study duration. Because of this concern regarding overall study
duration, we suggest that the therapy consolidation period be no more than 3 months in duration following the
3-month blanking period.
Recommendations regarding
repeat ablation
procedures
It is recommended that all clinical trials report the single procedure efficacy of catheter ablation. Success is defined
as freedom from symptomatic or asymptomatic AF/AFL/AT of 30 seconds or longer at 12 months postablation.
Recurrences of AF/AFL/AT during the first 3-month blanking period post-AF ablation are not considered a fail-
ure. Performance of a repeat ablation procedure at any point after the initial ablation procedure should be con-
sidered a failure of a single procedure strategy. It is acceptable for a clinical trial to choose to prespecify and use a
multiprocedure success rate as the primary endpoint of a clinical trial. When a multiprocedure success is selected
as the primary endpoint, efficacy should be defined as freedom from AF/flutter or tachycardia at 12 months after
the final ablation procedure. In the case of multiple procedures, repeat ablation procedures can be performed at
any time following the initial ablation procedure. All ablation procedures are subject to a 3-month post blanking
window, and all ablation trials should report efficacy at 12 months after the final ablation procedure.
Cardioversion definitions
Failed electrical
cardioversion
Failed electrical cardioversion is defined as the inability to restore sinus rhythm for 30 seconds or longer following
electrical cardioversion.
Successful electrical
cardioversion
Successful electrical cardioversion is defined as the ability to restore sinus rhythm for at least 30 seconds following
cardioversion.
Immediate AF recurrence
postcardioversion
Immediate AF recurrence postcardioversion is defined as a recurrence of AF within 24 hours following cardiover-
sion. The most common time for an immediate recurrence is within 30–60 minutes postcardioversion.
Early AF recurrence
postcardioversion
Early AF recurrence postcardioversion is defined as a recurrence of AF within 30 days of a successful cardioversion.
Late AF recurrence
postcardioversion
Late AF recurrence postcardioversion is defined as recurrence of AF more than 30 days following a successful
cardioversion.
Surgical ablation definitions
Hybrid AF surgical ablation
procedure
Hybrid AF surgical ablation procedure is defined as a joint AF ablation procedure performed by electrophysiologists
and cardiac surgeons either as part of a single “joint” procedure or performed as two preplanned separate abla-
tion procedures separated by no more than 6 months.
Surgical Maze ablation
procedure
Surgical Maze ablation procedure is defined as a surgical ablation procedure for AF that includes, at a minimum, the
following components: (1) line from SVC to IVC; (2) line from IVC to the tricuspid valve; (3) isolation of the PVs;
(4) isolation of the posterior left atrium; (5) line from MV to the PVs; (6) management of the LA appendage.
Stand-alone surgical AF
ablation
A surgical AF ablation procedure during which other cardiac surgical procedures are not performed such as CABG,
valve replacement, or valve repair.
Nomenclature for types of
surgical AF ablation
procedures
We recommend that the term “Maze” procedure is appropriately used only to refer to the biatrial lesion set of the
Cox-Maze operation. It requires ablation of the RA and LA isthmuses. Less extensive lesion sets should not be
referred to as a “Maze” procedure, but rather as a surgical AF ablation procedure. In general, surgical ablation
procedures for AF can be grouped into three different groups: (1) a full biatrial Cox-Maze procedure; (2) PVI
alone; and (3) PVI combined with left atrial lesion sets.
Hybrid epicardial and endo-
cardial AF ablation
This term refers to a combined AF ablation procedure involving an off-pump minimally invasive surgical AF ablation
as well as a catheter-based AF ablation procedure designed to complement the surgical lesion set. Hybrid abla-
tion procedures may be performed in a single-procedure setting in a hybrid operating room or a cardiac cath-
eterization laboratory environment, or it can be staged. When staged, it is most typical to have the patient
undergo the minimally invasive surgical ablation procedure first following by a catheter ablation procedure 1 to
3 months later. This latter approach is referred to as a “staged Hybrid AF ablation procedure.”
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Minimum AF documentation, endpoints, TEE performance, and success rates in clinical trials
Minimum documentation for
paroxysmal AF
The minimum AF documentation requirement for paroxysmal AF is (1) physician’s note indicating recurrent self-
terminating AF and (2) one electrocardiographically documented AF episode within 6 months prior to the abla-
tion procedure.
Minimum documentation for
persistent AF
The minimum AF documentation requirement for persistent AF is (1) physician’s note indicating continuous AF > 7
days but no more than 1 year and (2) a 24-hour Holter within 90 days of the ablation procedure showing con-
tinuous AF.
Minimum documentation for
early persistent AF
The minimum AF documentation requirement for persistent AF is (1) physician’s note indicating continuous AF > 7
days but no more than 3 months and (2) a 24-hour Holter showing continuous AF within 90 days of the ablation
procedure.
Minimum documentation for
long-standing persistent
AF
The minimum AF documentation requirement for long-standing persistent AF is as follows: physician’s note indicat-
ing at least 1 year of continuous AF plus a 24-hour Holter within 90 days of the ablation procedure showing con-
tinuous AF. The performance of a successful cardioversion (sinus rhythm >30 seconds) within 12 months of an
ablation procedure with documented early recurrence of AF within 30 days should not alter the classification of
AF as long-standing persistent.
Symptomatic AF/AFL/AT AF/AFL/AT that results in symptoms that are experienced by the patient. These symptoms can include but are not
limited to palpitations, presyncope, syncope, fatigue, and shortness of breath. For patients in continuous AF, re-
assessment of symptoms after restoration of sinus rhythm is recommended to establish the relationship between
symptoms and AF.
Documentation of AF-
related symptoms
Documentation by a physician evaluating the patient that the patient experiences symptoms that could be attribut-
able to AF. This does not require a time-stamped ECG, Holter, or event monitor at the precise time of symp-
toms. For patients with persistent AF who initially report no symptoms, it is reasonable to reassess symptom
status after restoration of sinus rhythm with cardioversion.
Minimum effectiveness end-
point for patients with
symptomatic and asymp-
tomatic AF
The minimum effectiveness endpoint is freedom from symptomatic and asymptomatic episodes of AF/AFL/AT re-
currences at 12 months following ablation, free from antiarrhythmic drug therapy, and including a prespecified
blanking period.
Minimum chronic acceptable
success rate: paroxysmal
AF at 12-month follow-up
If a minimum chronic success rate is selected as an objective effectiveness endpoint for a clinical trial, we recom-
mend that the minimum chronic acceptable success rate for paroxysmal AF at 12-month follow-up is 50%.
Minimum chronic acceptable
success rate: persistent AF
at 12-month follow-up
If a minimum chronic success rate is selected as an objective effectiveness endpoint for a clinical trial, we recom-
mend that the minimum chronic acceptable success rate for persistent AF at 12-month follow-up is 40%.
Minimum chronic acceptable
success rate: long-standing
persistent AF at 12-month
follow-up
If a minimum chronic success rate is selected as an objective effectiveness endpoint for a clinical trial, we recom-
mend that the minimum chronic acceptable success rate for long-standing persistent AF at 12-month follow-up is
30%.
Minimum follow-up screen-
ing for paroxysmal AF
recurrence
For paroxysmal AF, the minimum follow-up screening should include (1) 12-lead ECG at each follow-up visit; (2)
24-hour Holter at the end of the follow-up period (e.g., 12 months); and (3) event recording with an event moni-
tor regularly and when symptoms occur from the end of the 3-month blanking period to the end of follow-up
(e.g., 12 months).
Minimum follow-up screen-
ing for persistent or long-
standing AF recurrence
For persistent and long-standing persistent AF, the minimum follow-up screening should include (1) 12-lead ECG at
each follow-up visit; (2) 24-hour Holter every 6 months; and (3) symptom-driven event monitoring.
Requirements for transeso-
phageal echocardiogram
It is recommended that the minimum requirement for performance of a TEE in a clinical trial should be those re-
quirements set forth in ACC/AHA/HRS 2014 Guidelines for AF Management pertaining to anticoagulation at the
time of cardioversion. Prior to undergoing an AF ablation procedure a TEE should be performed in all patients
with AF of > 48 hours’ duration or of unknown duration if adequate systemic anticoagulation has not been main-
tained for at least 3 weeks prior to AF ablation. If a TEE is performed for this indication, it should be performed
within 24 hours of the ablation procedure.
AF, atrial fibrillation; DW-MRI, diffusion-weighted magnetic resonance imaging; CHF, congestive heart failure; QOL, quality of life; ECG, electrocardiogram; CABG, coronary ar-
tery bypass grafting; PV, pulmonary vein; SVC, superior vena cava; IVC, inferior vena cava; CFAE, complex fractionated atrial electrogram; PVI, pulmonary vein isolation; AFL,
atrial flutter; AT, atrial tachycardia; ACC, American College of Cardiology; AHA, American Heart Association; HRS, Heart Rhythm Society.
*When reporting outcomes of AF ablation, the development of atrial tachycardia or atrial flutter should be included in the broad definition of recurrence following AF ablation.
All studies should report freedom from AF, atrial tachycardia, and atrial flutter. These endpoints can also be reported separately. All studies should also clearly specify the type
and frequency of ECG monitoring as well as the degree of compliance with the prespecified monitoring protocol.
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Section 11: Training
Requirements
This section of the document outlines the training requirements for
those who wish to perform catheter ablation of AF.
Section 12: Surgical and Hybrid
AF Ablation
Please refer to Table 2 and Figure 8 presented earlier in this Executive
Summary.
Section 13: Clinical Trial Design
Although there have been many advances made in the field of
catheter and surgical ablation of AF, there is still much to be
learned about the mechanisms of initiation and maintenance of AF
and how to apply this knowledge to the still-evolving techniques
of AF ablation. Although single-center, observational reports have
dominated the early days of this field, we are quickly moving into
an era in which hypotheses are put through the rigor of testing in
well-designed, randomized, multicenter clinical trials. It is as a re-
sult of these trials that conventional thinking about the best tech-
niques, success rates, complication rates, and long-term outcomes
beyond AF recurrence—such as thromboembolism and
mortality—is being put to the test. The ablation literature has also
seen a proliferation of meta-analyses and other aggregate analyses,
which reinforce the need for consistency in the approach to re-
porting the results of clinical trials. This section reviews the min-
imum requirements for reporting on AF ablation trials. It also
acknowledges the potential limitations of using specific primary
outcomes and emphasizes the need for broad and consistent re-
porting of secondary outcomes to assist the end-user in determin-
ing not only the scientific, but also the clinical relevance of the
results (Tables 10–13).
Unanswered Questions in AF
Ablation
There is still much to be learned about the mechanisms of AF, tech-
niques of AF ablation, and long-term outcomes. The following are un-
answered questions for future investigation:
(1) AF ablation and modification of stroke risk and need for ongoing
oral anticoagulation (OAC): The CHA2DS2-VASc score was de-
veloped for patients with clinical AF. If a patient has received a suc-
cessful ablation such that he/she no longer has clinical AF
(subclinical, or no AF), then what is the need for ongoing OAC?
Are there any patients in whom successful ablation could lead to
discontinuation of OAC?
(2) Substrate modification in catheter-based management of AF—
particularly for persistent AF: What is the proper lesion set
required beyond pulmonary vein isolation? Do lines and com-
plex fractionated atrial electrogram (CFAE) have any
remaining role? Are these approaches ill-advised or simply
discouraged?
What is the role of targeting localized rotational activations? How
do we ablate a localized rotational activation? How can scar be
characterized and targeted for ablation? Do we need to replicate
the MAZE procedure? Does the right atrium need to be targeted
as well as the left atrium?
(3) Autonomic influence in AF: Is clinical AF really an autonomic medi-
ated arrhythmia? Is elimination of ganglionated plexi required? Is
there a role for autonomic modulation, for example, spinal cord
or vagal stimulation?
(4) Contribution and modulation of risk factors on outcomes of AF
ablation: Obesity reduction has been shown to reduce AF bur-
den and recurrence in patients undergoing ablation. What is
the role of bariatric surgery? Does the modulation of other risk
factors influence outcome such as hypertension, sleep apnea,
and diabetes?
(5) Outcomes in ablation of high-risk populations: Do high-risk popu-
lations benefit from AF ablation? Congestive heart failure has been
assessed in smaller trials, but larger trials are required. Outcome
data are needed in patients with very enlarged LAs, hypertrophic
cardiomyopathy, patients with renal failure on dialysis, and the
very elderly.
(6) Surgical vs catheter-based vs hybrid ablation: There should be
more comparative work between percutaneous and minimally in-
vasive surgical approaches. Both report similar outcomes, but
there is a dearth of comparative data. Is there any patient benefit
to hybrid procedures?
(7) How do we characterize patients who are optimal candidates for
ablation? Preablation late gadolinium-enhanced (LGE)-magnetic
resonance imaging (MRI) might identify patients with heavy bur-
dens of scar who are unlikely to respond to ablation. These tech-
niques must become reproducible and reliable and must be
assessed in multicenter trials. Other markers need to be investi-
gated, including genetic markers, biochemical markers, and clinical
markers based on aggregated risk scores.
(8) The incremental role of new technologies: As newer and often
more expensive technologies are produced for AF ablation,
their definitive incremental value must be determined in order
to justify change in practice or case cost. These technologies in-
clude global (basket) mapping techniques, newer ablation indi-
ces for assessing lesion durability, advanced imaging for viewing
lesions in the myocardium, etc. New energy sources, including
laser, low-intensity ultrasound, photonic particle therapy, ex-
ternal beam ablation, and MRI-guided ablation, must be as-
sessed in comparative fashion.
(9) Outcomes of AF ablation: We need to better understand the clin-
ical relevance of ablation outcomes. What is the significance of
time to recurrence of 30 seconds of arrhythmia? How do we best
quantify AF burden? How do these outcomes relate to quality of
life and stroke risk?
(10) What is the role of surgical LA reduction? Does left atrial append-
age (LAA) occlusion or obliteration improve outcome of persist-
ent AF ablation with an accompanying reduction in stroke? Does
ablation work through atrial size reduction? What is the incidence
of “stiff atrial” syndrome and does this mitigate the clinical impact
of ablation?
(11) Working in teams: What is the role of the entire heart team in AF
ablation? Does a team approach achieve better outcomes than a
“silo” approach?
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Table 11 Quality-of-life scales, definitions, and strengths
Scale Definition/Details Strengths/Weaknesses
Short Form (36) Health
Survey (SF36)38
(General)
Consists of 8 equally weighted, scaled scores in the
following sections: vitality, physical functioning,
bodily pain, general health perceptions, physical
role functioning, emotional role functioning, social
role functioning, mental health. Each section re-
ceives a scale score from 0 to 100.
Physical component summary (PCS) and mental
component summary (MCS) is an average of all
the physically and mentally relevant questions,
respectively.
The Short Form (12) Health Survey (SF12) is a
shorter version of the SF-36, which uses just 12
questions and still provides scores that can be
compared with SF-36 norms, especially for sum-
mary physical and mental functioning.
Gives more precision in measuring QOL than EQ-
5D but can be harder to transform into cost utility
analysis.
Advantages: extensively validated in a number of dis-
ease and health states. Might have more resolution
than EQ-50 for AF QOL.
Disadvantages: not specific for AF, so might not
have resolution to detect AF-specific changes in
QOL.
EuroQol Five
Dimensions
Questionnaire (EQ-
5D)39 (General)
Two components: Health state description is meas-
ured in five dimensions: mobility, self-care, usual
activities, pain/discomfort, anxiety/depression.
Answers may be provided on a three-level (3L)
or five-level (5L) scale. In the Evaluation section,
respondents evaluate their overall health status
using a visual analogue scale (EQ-VAS). Results
can easily be converted to quality-adjusted life
years for cost utility analysis.
Advantages: extensively validated in a number of dis-
ease and health states. Can easily be converted
into quality-adjusted life years for cost-effective-
ness analysis.
Disadvantages: might not be specific enough to de-
tect AF-specific changes in QOL. Might be less
specific than SF-36.
AF effect on Quality of
Life Survey
(AFEQT)40 (AF
specific)
20 questions: 4 targeting AF-related symptoms, 8
evaluating daily function, and 6 assessing AF treat-
ment concerns. Each item scored on a 7-point
Likert scale.
Advantages: brief, simple, very responsive to AF
interventions. Good internal validity and well vali-
dated against a number of other global and AF-
specific QOL scales. Used in CABANA.
Disadvantages: validation in only two published stud-
ies (approximately 219 patients).
Quality of Life
Questionnaire for
Patients with AF (AF-
QoL)41 (AF specific)
18-item self-administered questionnaire with three
domains: psychological, physical, and sexual activ-
ity. Each item scores on a 5-point Likert scale.
Advantages: brief, simple, responsive to AF interven-
tions; good internal validity; used in SARA trial.
Disadvantages: external validity compared only to
SF-36; formal validation in 1 study (approximately
400 patients).
Arrhythmia-Related
Symptom Checklist
(SCL)42 (AF specific)
16 items covering AF symptom frequency and symp-
tom severity.
Advantages: most extensively validated in a number
of arrhythmia cohorts and clinical trials.
Disadvantages: time-consuming and uncertain
generalizability.
Mayo AF Specific
Symptom Inventory
(MAFSI)43 (AF
specific)
10 items covering AF symptom frequency and sever-
ity. Combination of 5- point and 3-point Likert
scale responses.
Used in CABANA trial.
Advantages: validated in an AF ablation population
and responsive to ablation outcome; used in
CABANA trial.
Disadvantages: external validity compared only to
SF-36; 1 validation study (approximately 300
patients).
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Table 11 Continued
Scale Definition/Details Strengths/Weaknesses
University of Toronto
Atrial Fibrillation
Severity Scale (AFSS)
(AF specific)44
10 items covering frequency, duration, and severity.
7-point Likert scale responses.
Advantages: validated and reproducible; used in
CTAF trial.
Disadvantages: time-consuming and uncertain
generalizability.
Arrhythmia Specific
Questionnaire in
Tachycardia and
Arrhythmia (ASTA)45
(AF specific)
Records number of AF episodes and average epi-
sode duration during last 3 months. 8 symptoms
and 2 disabling symptoms are recorded with
scores from 1–4 for each.
Advantages: validated in various arrhythmia groups;
external validity compared with SCL, EQ5D, and
SF-36; used in MANTRA-PAF; brief; simple.
Disadvantages: one validation study (approximately
300 patients).
European Heart Rhythm
Association (EHRA)46
(AF specific)
Like NYHA scale. I = no symptoms, II = mild symp-
toms not affecting daily activity, III = severe symp-
toms affecting daily activity, and IV = disabling
symptoms terminating daily activities.
Advantage: very simple, like NYHA.
Disadvantages: not used in studies and not well vali-
dated; not very specific; unknown generalizability.
Canadian Cardiovascular
Society Severity of
Atrial Fibrillation Scale
(CCS-SAF)47 (AF
specific)
Like NYHA scale. O = asymptomatic, I = AF symp-
toms have minimal effect on patient’s QOL, II =
AF symptoms have minor effect on patient QOL,
III = symptoms have moderate effect on patient
QOL, IV= AF symptoms have severe effect on pa-
tient QOL.
Advantages: very simple, like NYHA; validated
against SF-36 and University of Toronto AFSS.
Disadvantages: poor correlation with subjective
AF burden; not very specific.
AF, atrial fibrillation; QOL, quality of life; CABANA, Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation; SARA, Study of Ablation Versus antiaRrhythmic
Drugs in Persistent Atrial Fibrillation; CTAF, Canadian Trial of Atrial Fibrillation; MANTRA-PAF, Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal
Atrial Fibrillation; NYHA, New York Heart Association; AFSS, atrial fibrillation severity scale.
....................................................................................................................................................................................................................
Table 12 Non-AF recurrence–related endpoints for reporting in AF ablation trials
Stroke and bleeding
endpoints
Definitions/Details
Stroke (2014 ACC/AHA Key
Data Elements)
An acute episode of focal or global neurological dysfunction caused by brain, spinal cord, or retinal vascular injury as a
result of hemorrhage or infarction. Symptoms or signs must persist >_24 hours, or if documented by CT, MRI or aut-
opsy, the duration of symptoms/signs may be less than 24 hours. Stroke may be classified as ischemic (including hem-
orrhagic transformation of ischemic stroke), hemorrhagic, or undetermined. Stroke disability measurement is
typically performed using the modified Rankin Scale (mRS).
Transient ischemic attack
(2014 ACC/AHA Key
Data Elements)
Transient episode of focal neurological dysfunction caused by brain, spinal cord, or retinal ischemia without acute in-
farction and with signs and symptoms lasting less than 24 hours.
Major bleeding (ISTH
definition)
Fatal bleeding AND/OR symptomatic bleeding in a critical area or organ, such as intracranial, intraspinal, intraocular,
retroperitoneal, intraarticular, pericardial, or intramuscular with compartment syndrome AND/OR bleeding causing
a fall in hemoglobin level of 2 g/dL (1.24 mmol/L) or more, or leading to transfusion of two or more units of blood.
Clinically relevant nonmajor
bleed (ISTH definition)
An acute or subacute clinically overt bleed that does not meet the criteria for a major bleed but prompts a clinical re-
sponse such that it leads to one of the following: hospital admission for bleeding; physician-guided medical or surgical
treatment for bleeding; change in antithrombotic therapy (including interruption or discontinuation).
Minor bleeding (ISTH
definition)
All nonmajor bleeds. Minor bleeds are further divided into clinically relevant and not.
Incidence and discontinu-
ation of oral
anticoagulation
The number of patients receiving oral anticoagulation and the type of oral anticoagulation should be documented at the
end of follow-up. If patients have their oral anticoagulation discontinued, the number of patients discontinuing, the
timing of discontinuation, and the reasons for discontinuation of oral anticoagulation, as well as the clinical character-
istics and stroke risk profile of the patients should be reported.
AF, atrial fibrillation; CT, computed tomography; MRI, magnetic resonance imaging.
184 Guidelines
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on 16 April 2018
....................................................................................................................................................................................................................
Table 13 Advantages and disadvantages of AF-related endpoints in AF ablation trials
Endpoint Advantages Disadvantages Relevance and Comments
Freedom from AF/AFL/AT
recurrence “gold stand-
ard” is 30 seconds
- Has been in use for many years
- Can be used to compare results
of new trials with historical
trials
- Sets a high bar for AF
elimination
- Can systematically underesti-
mate the efficacy of AF ablation,
particularly for persistent AF, if
30-second cutoff is used
- Particularly well suited for par-
oxysmal AF outcomes
- Reporting of cutoffs other
than 30 seconds encouraged
as secondary endpoints to
better contextualize results
- May be reported as propor-
tion of patients free from ar-
rhythmia or time to
recurrence
Freedom from stroke-rele-
vant AF/AFL/AT-duration
cutoff of 1 hour
- Useful for trials in which interest
is more for prognostic change
conferred by ablation rather
than elimination of all
arrhythmias
- No consistent definition of what
a stroke-relevant duration of
AF is: ranges from 6 minutes to
24 hours in literature
- More than 1 hour could be a
useful cutoff based on results
of 505 trial
- May be reported as propor-
tion of patients free from ar-
rhythmia or time to
recurrence
Freedom from AF/AFL/AT
requiring intervention
(emergency visits, cardio-
version, urgent care visit,
reablation, etc.)
- Can provide an endpoint more
relevant to systemic costs of AF
recurrence
- Clinically relevant
- Will overestimate efficacy of ab-
lation by ignoring shorter epi-
sodes not requiring
intervention that still might be
important to quality of life or
stroke
- Determination of what is an
“intervention” must be pre-
specified in protocol and
biases mitigated to avoid
over- or underintervention in
the trial
Freedom from persistent
AF/AFL/AT-duration cut-
off of 7 days
- Useful for trials assessing add-
itional substrate modification in
persistent AF
- Can systematically overestimate
the efficacy of AF ablation, par-
ticularly for persistent AF
- Can require continuous moni-
toring to definitively assess if
episode is > 7 days
Freedom from AF/AFL/AT
on previously ineffective
antiarrhythmic therapy
- If patient maintains sinus rhythm
on previously ineffective drug
therapy, this may be considered
a clinically relevant, successful
outcome
- Will increase the success rate
compared with off-drug success
- May not be relevant to patients
hoping to discontinue drug
therapy
- Postablation drug and dosage
of drug should be identical to
preablation drug and dosage
Significant reduction in AF
burden: >75% reduction
from pre- to postablation
and/or total postablation
burden <12%
- Can be useful in persistent AF
studies, but might not be suited
for early, paroxysmal AF
studies
- Ideally requires continuous
monitoring using an implantable
device
- No scientific basic exists show-
ing that a 75% reduction in AF
burden impacts hard endpoints,
including heart failure, stroke,
and mortality
- AF burden can be estimated
by intermittent monitoring
and reporting of patient symp-
toms and recurrences like a
“time in therapeutic range”
report for oral anticoagula-
tion; see text
- Could also see 75% reduction
in number and duration of AF
episodes
- Because there is no firm scien-
tific basis for selecting the cut-
off of 75%, this prior
recommendation is provided
only as an example of what fu-
ture clinical trials may choose
to use as a definition of clin-
ical/partial success
Prevention in AF progres-
sion: time to first episode
of persistent AF (>7 days)
- Does not assume that total
elimination of AF is required
- Prevention in progression might
be irrelevant for stroke or
thromboembolic outcomes
- Might be useful for specific
populations such as heart fail-
ure or hypertrophic
Continued
Guidelines 185
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on 16 April 2018
(12) Improving the safety of catheter ablation: As ablation extends
to more operators and less experienced operators, the statis-
tical occurrence of complications will increase. We need newer
techniques to minimize complications and institute standards
for operators to improve the reproducibility of ablation results
and safety profiles at a variety of centers worldwide.
(13) How does catheter ablation affect mortality, stroke, and hospital-
ization in broad and selected patient populations receiving cath-
eter ablation for AF?
(14) Management of patients who fail initial attempts at catheter abla-
tion: Should there be specific criteria for repeat ablations (e.g.,
atrial size, body mass index)? Should patients be referred for sur-
gery for repeat ablation?
In order to address these and other important questions in the
field of catheter and surgical AF ablation, we urge investigators to cre-
ate and participate in multisite collaborations and electrophysiology
research networks with involvement of senior and junior investiga-
tors on the steering committees to push forward the next phase of
AF research. We also urge funding bodies to support these important
initiatives.
Section 14: Conclusion
Catheter ablation of AF is a very commonly performed procedure in
hospitals throughout the world. This document provides an up-to-
date review of the indications, techniques, and outcomes of catheter
and surgical ablation of AF. Areas for which a consensus can be
reached concerning AF ablation are identified, and a series of consen-
sus definitions have been developed for use in future clinical trials of
AF ablation. Also included within this document are recommenda-
tions concerning indications for AF ablation, technical performance
of this procedure, and training. It is our hope to improve patient care
by providing a foundation for those involved with care of patients
with AF as well as those who perform AF ablation. It is recognized
that this field continues to evolve rapidly and that this document will
need to be updated. Successful AF ablation programs optimally
....................................................................................................................................................................................................................
Table 13 Continued
Endpoint Advantages Disadvantages Relevance and Comments
- Well suited for paroxysmal or
“early” AF studies in which goal
is to prevent progression to
persistent AF
- Long follow-up time might be
required unless population is
“enriched”
- Can ideally require continuous
implantable monitoring
cardiomyopathy, in which
progression to persistent AF
can lead to increased
hospitalization
Regression of AF: reduction
in burden to a given
threshold or conversion
of persistent to paroxys-
mal AF
- Does not assume that total
elimination of AF is required
- Well suited for persistent “late”
AF studies in which goal is to
regress to paroxysmal AF,
which might be easier to con-
trol with drug therapy
- Regression endpoint will over-
estimate efficacy of AF ablation
- Might ideally require continuous
implantable monitoring
- Patients will require ongoing
drug therapy
- Could be particularly useful
for long-standing persistent
AF populations with structural
heart disease, heart failure,
etc.
Acute AF termination during
ablation procedure
- Could provide indication of suc-
cessful modification of sub-
strate responsible for
maintaining AF, most relevant
to persistent or long-standing
persistent AF
- Limited studies have linked
acute AF termination to long-
term success
- Relevance of acute AF termin-
ation has not consistently been
shown to correlate to long-
term success
- Endpoint might not be relevant
to paroxysmal AF patients in
whom AF might terminate
spontaneously
- Some studies employ adminis-
tration of intravenous or oral
antiarrhythmics during ablation
that could cause spontaneous
termination
- Studies consider termination as
reversion to sinus rhythm,
whereas others consider rever-
sion to any regular tachycardia
as termination
- Intraprocedural administration
of preprocedural oral antiar-
rhythmics or intraprocedural
intravenous antiarrhythmics
are discouraged
- If antiarrhythmics are used,
their use and dosage before
and during the ablation should
be clearly documented
- Termination to sinus rhythm
and termination to another
regular tachycardia (AT or
AFL) should be separately
reported
AF, atrial fibrillation; AFL, atrial flutter; AT, atrial tachycardia.
186 Guidelines
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Guidelines 187
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t.
Ju
de
M
ed
ic
al
1:
St
.J
ud
e
M
ed
ic
al
2:
Bi
os
en
se
W
eb
st
er
,
2:
St
.J
ud
e
M
ed
ic
al
N
on
e
N
on
e
N
on
e
M
in
a
K
.C
hu
ng
,M
D
C
le
ve
la
nd
C
lin
ic
,C
le
ve
la
nd
,
O
H
0:
A
m
ar
in
,0
:B
IO
T
R
O
N
IK
,0
:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,0
:
M
ed
tr
on
ic
,I
nc
.,
0:
St
.J
ud
e
M
ed
ic
al
,0
:Z
ol
lM
ed
ic
al
C
or
po
ra
tio
n
1:
A
m
er
ic
an
C
ol
le
ge
of
C
ar
di
ol
og
y
N
on
e
N
on
e
N
on
e
1:
U
p
to
D
at
e
Je
ns
C
os
ed
is
N
ie
ls
en
,
D
M
Sc
,P
hD
A
ar
hu
s
U
ni
ve
rs
ity
H
os
pi
ta
l,
Sk
ej
by
,D
en
m
ar
k
N
on
e
N
on
e
5.
N
ov
o
N
or
di
sk
Fo
un
da
tio
n
N
on
e
N
on
e
N
on
e
A
nn
e
B.
C
ur
tis
,M
D
U
ni
ve
rs
ity
at
Bu
ffa
lo
,B
uf
fa
lo
,
N
Y
1:
D
ai
ic
hi
-S
an
ky
o,
1:
M
ed
tr
on
ic
,I
nc
.,
1:
Pr
oj
ec
ts
in
K
no
w
le
dg
e,
2:
St
.J
ud
e
M
ed
ic
al
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
Co
nt
in
ue
d
188 Guidelines
Downloaded from https://academic.oup.com/europace/article-abstract/20/1/157/4158231
by CNIC Fundación Centro Nacional de Investigaciones Cardiovasculares user
on 16 April 2018
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...
A
p
p
e
n
d
ix
A
C
o
n
ti
n
u
e
d
W
ri
ti
n
g
g
ro
u
p
m
e
m
b
e
r
In
st
it
u
ti
o
n
C
o
n
su
lt
a
n
t/
A
d
v
is
o
ry
b
o
a
rd
/H
o
n
o
ra
ri
a
S
p
e
a
k
e
rs
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b
u
re
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u
R
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se
a
rc
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g
ra
n
t
F
e
ll
o
w
sh
ip
su
p
p
o
rt
S
to
c
k
o
p
ti
o
n
s/
P
a
rt
n
e
r
B
o
a
rd
M
b
s/
O
th
e
r
D
.W
yn
D
av
ie
s,
M
D
Im
pe
ri
al
C
ol
le
ge
H
ea
lth
ca
re
N
H
S
T
ru
st
,L
on
do
n,
U
ni
te
d
K
in
gd
om
1:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,1
:
Ja
ns
se
n
Ph
ar
m
ac
eu
tic
al
s,
1:
M
ed
tr
on
ic
,I
nc
.,
1:
R
hy
th
m
ia
M
ed
ic
al
N
on
e
N
on
e
N
on
e
3:
R
hy
th
m
ia
M
ed
ic
al
N
on
e
Jo
hn
D
.D
ay
,M
D
In
te
rm
ou
nt
ai
n
M
ed
ic
al
C
en
te
r
H
ea
rt
In
st
itu
te
,S
al
t
La
ke
C
ity
,U
T
1:
BI
O
T
R
O
N
IK
,1
:B
os
to
n
Sc
ie
nt
ifi
c
C
or
p.
,3
:S
t.
Ju
de
M
ed
ic
al
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
A
nd
re´
d’
A
vi
la
,M
D
,
Ph
D
H
os
pi
ta
lS
O
S
C
ar
di
o,
Fl
or
ia
no
po
lis
,S
C
,B
ra
zi
l
N
on
e
0:
BI
O
T
R
O
N
IK
,0
:S
t.
Ju
de
M
ed
ic
al
0:
BI
O
T
R
O
N
IK
,0
:S
t.
Ju
de
M
ed
ic
al
N
on
e
N
on
e
N
on
e
N
.M
.S
.(
N
at
as
ja
)
de
G
ro
ot
,M
D
,P
hD
Er
as
m
us
M
ed
ic
al
C
en
te
r,
R
ot
te
rd
am
,t
he
N
et
he
rl
an
ds
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
Lu
ig
iD
iB
ia
se
,M
D
,
Ph
D
A
lb
er
t
Ei
ns
te
in
C
ol
le
ge
of
M
ed
ic
in
e,
M
on
te
fio
re
-
Ei
ns
te
in
C
en
te
r
fo
r
H
ea
rt
&
V
as
cu
la
r
C
ar
e,
Br
on
x,
N
Y
1:
A
tr
ic
ur
e,
1:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
1:
BI
O
T
R
O
N
IK
,1
:B
os
to
n
Sc
ie
nt
ifi
c
C
or
p.
,1
:E
pi
EP
,1
:
M
ed
tr
on
ic
,I
nc
.,
1:
St
.J
ud
e
M
ed
ic
al
,1
:S
te
re
ot
ax
is
,I
nc
.
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
M
at
tia
s
D
uy
ts
ch
ae
ve
r,
M
D
,P
hD
U
ni
ve
rs
ita
ir
Z
ie
ke
nh
ui
s
G
en
t
(G
he
nt
U
ni
ve
rs
ity
H
os
pi
ta
l),
G
he
nt
,B
el
gi
um
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
Ja
m
es
R
.E
dg
er
to
n,
M
D
T
he
H
ea
rt
H
os
pi
ta
l,
Ba
yl
or
Pl
an
o,
Pl
an
o,
T
X
2:
A
tr
iC
ur
e,
In
c.
1:
A
tr
iC
ur
e,
In
c.
2:
A
tr
iC
ur
e,
In
c.
N
on
e
N
on
e
N
on
e
K
en
ne
th
A
.
El
le
nb
og
en
,M
D
V
ir
gi
ni
a
C
om
m
on
w
ea
lth
U
ni
ve
rs
ity
Sc
ho
ol
of
M
ed
ic
in
e,
R
ic
hm
on
d,
V
A
1:
A
m
er
ic
an
H
ea
rt
A
ss
oc
ia
tio
n,
1:
H
ea
rt
R
hy
th
m
So
ci
et
y,
2:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
1:
A
tr
iC
ur
e,
In
c.
,1
:
Bi
os
en
se
W
eb
st
er
,
In
c.
,1
:
BI
O
T
R
O
N
IK
,1
:S
t.
Ju
de
M
ed
ic
al
,2
:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,2
:
M
ed
tr
on
ic
,I
nc
.
2:
Bi
os
en
se
W
eb
st
er
,
In
c.
,2
:D
ai
ic
hi
-
Sa
nk
yo
,2
:N
at
io
na
l
In
st
itu
te
s
of
H
ea
lth
,
4:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,4
:
M
ed
tr
on
ic
,I
nc
.
N
on
e
N
on
e
1:
El
se
vi
er
,1
:
W
ile
y-
Bl
ac
kw
el
l
Pa
tr
ic
k
T
.E
lli
no
r,
M
D
,P
hD
M
as
sa
ch
us
et
ts
G
en
er
al
H
os
pi
ta
l,
Bo
st
on
,M
A
1:
Ba
ye
r
H
ea
lth
C
ar
e,
LL
C
,1
:
Q
ue
st
D
ia
gn
os
tic
s
N
on
e
1:
Le
du
cq
Fo
un
da
tio
n,
3:
A
m
er
ic
an
H
ea
rt
A
ss
oc
ia
tio
n,
3:
N
at
io
na
lI
ns
tit
ut
es
of
H
ea
lth
,5
:B
ay
er
H
ea
lth
C
ar
e,
LL
C
N
on
e
N
on
e
N
on
e
Co
nt
in
ue
d
Guidelines 189
Downloaded from https://academic.oup.com/europace/article-abstract/20/1/157/4158231
by CNIC Fundación Centro Nacional de Investigaciones Cardiovasculares user
on 16 April 2018
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A
p
p
e
n
d
ix
A
C
o
n
ti
n
u
e
d
W
ri
ti
n
g
g
ro
u
p
m
e
m
b
e
r
In
st
it
u
ti
o
n
C
o
n
su
lt
a
n
t/
A
d
v
is
o
ry
b
o
a
rd
/H
o
n
o
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a
S
p
e
a
k
e
rs
’
b
u
re
a
u
R
e
se
a
rc
h
g
ra
n
t
F
e
ll
o
w
sh
ip
su
p
p
o
rt
S
to
c
k
o
p
ti
o
n
s/
P
a
rt
n
e
r
B
o
a
rd
M
b
s/
O
th
e
r
Sa
bi
ne
Er
ns
t,
M
D
,
Ph
D
R
oy
al
Br
om
pt
on
an
d
H
ar
efi
el
d
N
H
S
Fo
un
da
tio
n
T
ru
st
,N
at
io
na
lH
ea
rt
an
d
Lu
ng
In
st
itu
te
,I
m
pe
ri
al
C
ol
le
ge
Lo
nd
on
,L
on
do
n,
U
ni
te
d
K
in
gd
om
2:
Bi
os
en
se
W
eb
st
er
,I
nc
.
N
on
e
4:
Sp
ec
tr
um
D
yn
am
ic
s
N
on
e
N
on
e
N
on
e
G
ui
lh
er
m
e
Fe
ne
lo
n,
M
D
,P
hD
A
lb
er
t
Ei
ns
te
in
Je
w
is
h
H
os
pi
ta
l,
Fe
de
ra
l
U
ni
ve
rs
ity
of
S~ a
o
Pa
ul
o,
S~ a
o
Pa
ul
o,
Br
az
il
1:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
1:
BI
O
T
R
O
N
IK
,1
:S
t.
Ju
de
M
ed
ic
al
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
Ed
w
ar
d
P.
G
er
st
en
fe
ld
,M
S,
M
D
U
ni
ve
rs
ity
of
C
al
ifo
rn
ia
,S
an
Fr
an
ci
sc
o,
Sa
n
Fr
an
ci
sc
o,
C
A
1:
Bo
eh
ri
ng
er
In
ge
lh
ei
m
,1
:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,1
:
M
ed
tr
on
ic
,I
nc
.,
1:
St
.J
ud
e
M
ed
ic
al
N
on
e
4:
Bi
os
en
se
W
eb
st
er
,
In
c.
,4
:S
t.
Ju
de
M
ed
ic
al
2:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
2:
BI
O
T
R
O
N
IK
,
2:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,
2:
M
ed
tr
on
ic
,
In
c.
1:
R
hy
th
m
D
ia
gn
os
tic
Sy
st
em
s
In
c.
N
on
e
D
av
id
E.
H
ai
ne
s,
M
D
Be
au
m
on
t
H
ea
lth
Sy
st
em
,
R
oy
al
O
ak
,M
I
1:
La
ke
R
eg
io
n
M
ed
ic
al
,1
:
T
er
um
o
M
ed
ic
al
C
or
p
N
on
e
N
on
e
N
on
e
N
on
e
1:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
1:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,1
:
M
ed
tr
on
ic
,
In
c.
,1
:S
t.
Ju
de
M
ed
ic
al
M
ic
he
lH
ai
ss
ag
ue
rr
e,
M
D
H
oˆp
ita
lC
ar
di
ol
og
iq
ue
du
H
au
t-
Le´
veˆ
qu
e,
Pe
ss
ac
,
Fr
an
ce
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
R
ob
er
t
H
.H
el
m
,M
D
Bo
st
on
U
ni
ve
rs
ity
M
ed
ic
al
C
en
te
r,
Bo
st
on
,M
A
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
1:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
El
ai
ne
H
yl
ek
,M
D
,
M
PH
Bo
st
on
U
ni
ve
rs
ity
Sc
ho
ol
of
M
ed
ic
in
e,
Bo
st
on
,M
A
1:
Ba
ye
r,
1:
Bo
eh
ri
ng
er
In
ge
lh
ei
m
,1
:B
ri
st
ol
-M
ye
rs
Sq
ui
bb
,1
:D
ai
ic
hi
-S
an
ky
o,
1:
M
ed
tr
on
ic
,1
:P
or
to
la
,1
:
Pfi
ze
r
N
on
e
2:
Ja
ns
se
n
Ph
ar
m
ac
eu
tic
al
s
N
on
e
N
on
e
N
on
e
Co
nt
in
ue
d
190 Guidelines
Downloaded from https://academic.oup.com/europace/article-abstract/20/1/157/4158231
by CNIC Fundación Centro Nacional de Investigaciones Cardiovasculares user
on 16 April 2018
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...
A
p
p
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n
d
ix
A
C
o
n
ti
n
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W
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ti
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g
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In
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it
u
ti
o
n
C
o
n
su
lt
a
n
t/
A
d
v
is
o
ry
b
o
a
rd
/H
o
n
o
ra
ri
a
S
p
e
a
k
e
rs
’
b
u
re
a
u
R
e
se
a
rc
h
g
ra
n
t
F
e
ll
o
w
sh
ip
su
p
p
o
rt
S
to
c
k
o
p
ti
o
n
s/
P
a
rt
n
e
r
B
o
a
rd
M
b
s/
O
th
e
r
W
ar
re
n
M
.J
ac
km
an
,
M
D
H
ea
rt
R
hy
th
m
In
st
itu
te
,
U
ni
ve
rs
ity
of
O
kl
ah
om
a
H
ea
lth
Sc
ie
nc
es
C
en
te
r,
O
kl
ah
om
a
C
ity
,O
K
1:
A
C
T
,1
:V
yt
ro
nU
S,
In
c.
,2
:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
2:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,2
:
Sp
ec
tr
um
D
yn
am
ic
s
1:
BI
O
T
R
O
N
IK
,1
:S
t.
Ju
de
M
ed
ic
al
,2
:
Bi
os
en
se
W
eb
st
er
,
In
c.
,2
:B
os
to
n
Sc
ie
nt
ifi
c
C
or
p.
N
on
e
N
on
e
N
on
e
N
on
e
Jo
se
Ja
lif
e,
M
D
U
ni
ve
rs
ity
of
M
ic
hi
ga
n,
A
nn
A
rb
or
,M
I,
th
e
N
at
io
na
l
C
en
te
r
fo
r
C
ar
di
ov
as
cu
la
r
R
es
ea
rc
h
C
ar
lo
s
III
(C
N
IC
)
an
d
C
IB
ER
C
V
,M
ad
ri
d,
Sp
ai
n
1:
T
op
er
a
M
ed
ic
al
N
on
e
1:
M
ed
tr
on
ic
,I
nc
.
N
on
e
N
on
e
N
on
e
Jo
na
th
an
M
.K
al
m
an
,
M
BB
S,
Ph
D
R
oy
al
M
el
bo
ur
ne
H
os
pi
ta
l
an
d
U
ni
ve
rs
ity
of
M
el
bo
ur
ne
,M
el
bo
ur
ne
,
A
us
tr
al
ia
N
on
e
1:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,1
:
M
ed
tr
on
ic
,I
nc
.
4:
M
ed
tr
on
ic
,I
nc
.
3:
St
.J
ud
e
M
ed
ic
al
,
4:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
4:
M
ed
tr
on
ic
,
In
c.
N
on
e
2:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
4:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
Jo
se
fK
au
tz
ne
r,
M
D
,
Ph
D
In
st
itu
te
fo
r
C
lin
ic
al
an
d
Ex
pe
ri
m
en
ta
lM
ed
ic
in
e,
Pr
ag
ue
,C
ze
ch
R
ep
ub
lic
1:
Ba
ye
r/
Sc
he
ri
ng
Ph
ar
m
a,
1:
Bo
eh
ri
ng
er
In
ge
lh
ei
m
,1
:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,1
:
D
ai
ic
hi
-S
an
ky
o,
1:
So
ri
n
G
ro
up
,1
:S
t.
Ju
de
M
ed
ic
al
,
1:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
2:
M
ed
tr
on
ic
,I
nc
.
1:
BI
O
T
R
O
N
IK
1:
M
ed
tr
on
ic
,I
nc
.
1:
St
.J
ud
e
M
ed
ic
al
N
on
e
N
on
e
N
on
e
N
on
e
H
an
s
K
ot
tk
am
p,
M
D
H
ir
sl
an
de
n
H
os
pi
ta
l,
D
ep
t.
of
El
ec
tr
op
hy
si
ol
og
y,
Z
ur
ic
h,
Sw
itz
er
la
nd
1:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
1:
K
ar
di
um
N
on
e
N
on
e
N
on
e
1:
K
ar
di
um
N
on
e
K
ar
lH
ei
nz
K
uc
k,
M
D
,
Ph
D
A
sk
le
pi
os
K
lin
ik
St
.G
eo
rg
,
H
am
bu
rg
,G
er
m
an
y
1:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
1:
BI
O
T
R
O
N
IK
,1
:S
t.
Ju
de
M
ed
ic
al
,1
:S
te
re
ot
ax
is
,I
nc
.
N
on
e
1:
Bi
os
en
se
W
eb
st
er
,
In
c.
,1
:
BI
O
T
R
O
N
IK
,1
:S
t.
Ju
de
M
ed
ic
al
,1
:
St
er
eo
ta
xi
s,
In
c.
N
on
e
1:
En
do
se
ns
e
N
on
e
K
oi
ch
ir
o
K
um
ag
ai
,
M
D
,P
hD
H
ea
rt
R
hy
th
m
C
en
te
r,
Fu
ku
ok
a
Sa
nn
o
H
os
pi
ta
l,
Fu
ku
ok
a,
Ja
pa
n
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
R
ic
ha
rd
Le
e,
M
D
,
M
BA
Sa
in
t
Lo
ui
s
U
ni
ve
rs
ity
M
ed
ic
al
Sc
ho
ol
,S
t.
Lo
ui
s,
M
O
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
Co
nt
in
ue
d
Guidelines 191
Downloaded from https://academic.oup.com/europace/article-abstract/20/1/157/4158231
by CNIC Fundación Centro Nacional de Investigaciones Cardiovasculares user
on 16 April 2018
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A
p
p
e
n
d
ix
A
C
o
n
ti
n
u
e
d
W
ri
ti
n
g
g
ro
u
p
m
e
m
b
e
r
In
st
it
u
ti
o
n
C
o
n
su
lt
a
n
t/
A
d
v
is
o
ry
b
o
a
rd
/H
o
n
o
ra
ri
a
S
p
e
a
k
e
rs
’
b
u
re
a
u
R
e
se
a
rc
h
g
ra
n
t
F
e
ll
o
w
sh
ip
su
p
p
o
rt
S
to
c
k
o
p
ti
o
n
s/
P
a
rt
n
e
r
B
o
a
rd
M
b
s/
O
th
e
r
T
ho
rs
te
n
Le
w
al
te
r,
M
D
,P
hD
D
ep
t.
of
C
ar
di
ol
og
y
an
d
In
te
ns
iv
e
C
ar
e,
H
os
pi
ta
l
M
un
ic
h-
T
ha
lk
ir
ch
en
,
M
un
ic
h,
G
er
m
an
y
1:
BI
O
T
R
O
N
IK
,1
:M
ed
tr
on
ic
,
In
c.
,1
:S
t.
Ju
de
M
ed
ic
al
1:
A
bb
ot
t
V
as
cu
la
r,
1:
BI
O
T
R
O
N
IK
,1
:
M
ed
tr
on
ic
,I
nc
.,
1:
St
.J
ud
e
M
ed
ic
al
N
on
e
N
on
e
N
on
e
N
on
e
Br
uc
e
D
.L
in
ds
ay
,
M
D
C
le
ve
la
nd
C
lin
ic
,C
le
ve
la
nd
,
O
H
0:
M
ed
tr
on
ic
,I
nc
.,
1:
A
bb
ot
t
V
as
cu
la
r,
1:
Bi
os
en
se
W
eb
st
er
,I
nc
.
N
on
e
N
on
e
3:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,
3:
M
ed
tr
on
ic
,
In
c.
,3
:S
t.
Ju
de
M
ed
ic
al
N
on
e
N
on
e
La
ur
en
t
M
ac
le
,M
D
M
on
tr
ea
lH
ea
rt
In
st
itu
te
,
D
ep
ar
tm
en
t
of
M
ed
ic
in
e,
U
ni
ve
rs
ite´
de
M
on
tr
e´a
l,
M
on
tr
e´a
l,
C
an
ad
a
1:
Ba
ye
r
H
ea
lth
C
ar
e,
LL
C
,1
:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
1:
Bo
eh
ri
ng
er
In
ge
lh
ei
m
,1
:
Br
is
to
l-M
ye
rs
Sq
ui
bb
,1
:
M
ed
tr
on
ic
,I
nc
.,
1:
Pfi
ze
r,
In
c.
,1
:S
er
vi
er
,1
:S
t.
Ju
de
M
ed
ic
al
N
on
e
4:
Bi
os
en
se
W
eb
st
er
,
In
c.
,5
:S
t.
Ju
de
M
ed
ic
al
N
on
e
N
on
e
N
on
e
M
ou
ss
a
M
an
so
ur
,
M
D
M
as
sa
ch
us
et
ts
G
en
er
al
H
os
pi
ta
l,
Bo
st
on
,M
A
1:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
1:
St
.J
ud
e
M
ed
ic
al
N
on
e
4:
Bi
os
en
se
W
eb
st
er
,
In
c.
,4
:S
t.
Ju
de
M
ed
ic
al
,5
:P
fiz
er
,5
:
Bo
eh
ri
ng
er
In
ge
lh
ei
m
N
on
e
4:
N
ew
Pa
ce
Lt
d.
N
on
e
Fr
an
ci
s
E.
M
ar
ch
lin
sk
i,
M
D
H
os
pi
ta
lo
ft
he
U
ni
ve
rs
ity
of
Pe
nn
sy
lv
an
ia
,U
ni
ve
rs
ity
of
Pe
nn
sy
lv
an
ia
Sc
ho
ol
of
M
ed
ic
in
e,
Ph
ila
de
lp
hi
a,
PA
1:
A
bb
ot
M
ed
ic
al
;1
:B
io
se
ns
e
W
eb
st
er
,I
nc
.,
2:
BI
O
T
R
O
N
IK
,1
:M
ed
tr
on
ic
,
In
c.
,1
:B
os
to
n
Sc
ie
nt
ifi
c
C
or
p.
,1
:S
t.
Ju
de
M
ed
ic
al
N
on
e
3:
M
ed
tr
on
ic
,I
nc
.,
4:
Bi
os
en
se
W
eb
st
er
,
In
c.
1:
BI
O
T
R
O
N
IK
,3
:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,
3:
M
ed
tr
on
ic
,
In
c.
,4
:B
io
se
ns
e
W
eb
st
er
,I
nc
.,
5:
St
.J
ud
e
M
ed
ic
al
N
on
e
N
on
e
G
re
go
ry
F.
M
ic
ha
ud
,
M
D
Br
ig
ha
m
an
d
W
om
en
’s
H
os
pi
ta
l,
Bo
st
on
,M
A
1:
Bi
os
en
se
W
eb
st
er
,I
nc
.,
1:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,1
:
M
ed
tr
on
ic
,I
nc
.,
1:
St
.J
ud
e
M
ed
ic
al
N
on
e
4:
Bi
os
en
se
W
eb
st
er
,
In
c.
,4
:B
os
to
n
Sc
ie
nt
ifi
c
C
or
p.
N
on
e
N
on
e
N
on
e
H
ir
os
hi
N
ak
ag
aw
a,
M
D
,P
hD
H
ea
rt
R
hy
th
m
In
st
itu
te
,
U
ni
ve
rs
ity
of
O
kl
ah
om
a
H
ea
lth
Sc
ie
nc
es
C
en
te
r,
O
kl
ah
om
a
C
ity
,O
K
2:
Bi
os
en
se
W
eb
st
er
,I
nc
1:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,2
:
St
er
eo
ta
xi
s,
In
c.
,3
:J
ap
an
Li
fe
lin
e,
3:
Fu
ku
da
D
en
sh
i
1:
M
ed
tr
on
ic
,I
nc
,2
:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,1
:S
pe
ct
ru
m
D
yn
am
ic
s
4:
Bi
os
en
se
W
eb
st
er
,
In
c.
,2
:J
ap
an
Li
fe
lin
e,
2:
A
ffe
ra
N
on
e
N
on
e
N
on
e
Co
nt
in
ue
d
192 Guidelines
Downloaded from https://academic.oup.com/europace/article-abstract/20/1/157/4158231
by CNIC Fundación Centro Nacional de Investigaciones Cardiovasculares user
on 16 April 2018
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A
p
p
e
n
d
ix
A
C
o
n
ti
n
u
e
d
W
ri
ti
n
g
g
ro
u
p
m
e
m
b
e
r
In
st
it
u
ti
o
n
C
o
n
su
lt
a
n
t/
A
d
v
is
o
ry
b
o
a
rd
/H
o
n
o
ra
ri
a
S
p
e
a
k
e
rs
’
b
u
re
a
u
R
e
se
a
rc
h
g
ra
n
t
F
e
ll
o
w
sh
ip
su
p
p
o
rt
S
to
c
k
o
p
ti
o
n
s/
P
a
rt
n
e
r
B
o
a
rd
M
b
s/
O
th
e
r
A
nd
re
a
N
at
al
e,
M
D
T
ex
as
C
ar
di
ac
A
rr
hy
th
m
ia
In
st
itu
te
,S
t.
D
av
id
’s
M
ed
ic
al
C
en
te
r,
A
us
tin
,T
X
1:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,1
:
Ja
ns
se
n
Ph
ar
m
ac
eu
tic
al
s,
1:
M
ed
tr
on
ic
,I
nc
.,
1:
St
.J
ud
e
M
ed
ic
al
,2
:B
io
se
ns
e
W
eb
st
er
,I
nc
.
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
St
an
le
y
N
at
te
l,
M
D
M
on
tr
ea
lH
ea
rt
In
st
itu
te
an
d
U
ni
ve
rs
ite´
de
M
on
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,1
:
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Pa
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.,
0:
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0:
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hn
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Sy
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.J
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1:
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us
,1
:
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an
se
n
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,1
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:
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:
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,1
:
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xf
or
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Pr
es
s
(R
oy
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ty
),
1:
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EM
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S,
1:
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D
,1
:
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ac
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l
(R
oy
al
ty
),
2:
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os
en
se
W
eb
st
er
,4
:S
t.
Ju
de
M
ed
ic
al
(R
oy
al
ty
) Co
nt
in
ue
d
Guidelines 193
Downloaded from https://academic.oup.com/europace/article-abstract/20/1/157/4158231
by CNIC Fundación Centro Nacional de Investigaciones Cardiovasculares user
on 16 April 2018
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A
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C
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R
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In
st
itu
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of
C
ir
cu
la
tio
n
Pa
th
ol
og
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N
ov
os
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ir
sk
,R
us
si
a
1:
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os
en
se
W
eb
st
er
,I
nc
.,
1:
Bo
st
on
Sc
ie
nt
ifi
c
C
or
p.
,1
:
M
ed
tr
on
ic
,I
nc
.
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
M
at
th
ew
R
.
R
ey
no
ld
s,
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La
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rl
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1:
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os
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1:
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.,
1:
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.J
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M
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N
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N
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ha
nt
ha
n
Sa
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BB
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Ph
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fo
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H
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R
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,S
ou
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A
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tr
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ia
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H
ea
lth
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d
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al
R
es
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In
st
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te
,
U
ni
ve
rs
ity
of
A
de
la
id
e
an
d
R
oy
al
A
de
la
id
e
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os
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ta
l,
A
de
la
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e,
A
us
tr
al
ia
1:
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os
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se
W
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st
er
,I
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.,
1:
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st
on
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ie
nt
ifi
c
C
or
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,1
:
C
at
hR
x,
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tr
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ic
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.,
1:
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.J
ud
e
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,
In
c.
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c
C
or
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:
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,I
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.,
1:
St
.J
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e
M
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al
4:
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ri
n
G
ro
up
,5
:
BI
O
T
R
O
N
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,5
:
Bo
st
on
Sc
ie
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C
or
p.
,5
:
M
ed
tr
on
ic
,I
nc
.,
5:
St
.J
ud
e
M
ed
ic
al
N
on
e
N
on
e
N
on
e
M
au
ri
ci
o
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an
av
ac
ca
,
M
D
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In
st
itu
to
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or
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~ ao
(In
C
or
),
S~ a
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o,
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az
il
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st
er
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1:
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.J
ud
e
M
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1:
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ye
r/
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he
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ar
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1:
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-
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nk
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2:
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an
d
Jo
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2:
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hn
so
n
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hi
lli
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D
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rt
s
H
ea
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tr
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Lo
nd
on
,
U
ni
te
d
K
in
gd
om
1:
Bi
os
en
se
W
eb
st
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,I
nc
.,
1:
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eh
ri
ng
er
In
ge
lh
ei
m
,1
:
D
ai
ic
hi
-S
an
ky
o,
1:
H
an
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M
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,1
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ed
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.,
1:
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.J
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1:
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,4
:
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:
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4:
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la
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T
on
do
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D
,
Ph
D
C
ar
di
ac
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hy
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ia
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r,
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ar
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on
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no
,
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C
C
S,
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tm
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of
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ar
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cu
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r
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es
,
U
ni
ve
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ity
of
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ila
n,
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ila
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Ita
ly
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
N
on
e
Co
nt
in
ue
d
194 Guidelines
Downloaded from https://academic.oup.com/europace/article-abstract/20/1/157/4158231
by CNIC Fundación Centro Nacional de Investigaciones Cardiovasculares user
on 16 April 2018
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of
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Guidelines 195
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196 Guidelines
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Guidelines 197
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by CNIC Fundación Centro Nacional de Investigaciones Cardiovasculares user
on 16 April 2018
should consist of a cooperative team of cardiologists, electrophysi-
ologists, and surgeons to ensure appropriate indications, procedure
selection, and follow-up.
The full article HRS/EHRA/APHRS/ECAS/SOLAECE Expert Consensus
Statement on Catheter and Surgical Ablation of Atrial Fibrillation can be
read in full online. When referencing please cite the full article
[10.1093/europace/eux274].
Acknowledgments
The authors acknowledge the support of Jun Dong, MD, PhD; Kan
Fang, MD; and Mark Fellman at the Division of Cardiovascular
Devices, Center for Devices and Radiological Health, U.S. Food and
Drug Administration (FDA) during the preparation of this document.
This document does not necessarily represent the opinions, policies,
or recommendations of the FDA.
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