1. Asklepios Klink St. Georg, Hamburg
HRS/EHRA/ECAS Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation
K.R. Julian Chun
Asklepios Klink St. Georg, Hamburg

2. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation
Fuster et al. Circulation 2006;114:

3. Catheter ablation of atrial fibrillation
SUCCESS RATES
Looking into published data on success rates for AF ablation using RF energy in a total of 1039 pts summarized by Verma et al shows very nicely consistent success rates of approximately 80% despite the use of different ablation techniques and ablation endpoints.
Verma A et al. (Circulation 2005;112:1214–1231)

4. Catheter ablation of atrial fibrillation COMPLICATIONS – LARGE Centers
The overall complication rate in this pooled data analysis was 2.8% (29/1033 pts). Major irreversible complications such as permanent stroke (n=1) and severe PV stenosis was (n=3) was fairly low.
Pooled data complication rate: 2.8%
Verma A et al. (Circulation 2005;112:1214–1231)

5. Catheter ablation of atrial fibrillation
COMPLICATIONS - World Wide Survey
The situation in „real world“ however may be different. In this world wide survey published from Cappato et al. the overall complication rate was higher accounting to almost 6%. n= %
Cappato et al. Circulation 2005; 111;

6. Prevalence Atrial Fibrillation
7.0
6.0
5.0
4.0
3.0
2.0
1.0
5.61
5.42
5.16
4.78
4.34
3.80
Adults with atrial fibrillation [millions]
3.33
2.94
2.66
2.44
The estimated AF prevalence here calculated for the USA will dramatically increase over the next years. Risiko für AF steigt um 0.4% pro Lebensjahr. Inzidenz 0,1 % in 40jährigen, 2% in 80 j. und 10%in NYHA Pat.
2.26
2.08
Year
Go et al, JAMA 2001;285:2370

7. Heart Rhythm Jun;4(6):

8. Definitions Atrial Fibrillation (AF)
HRS/EHRA/ECAS Consensus Statement
Definitions Atrial Fibrillation (AF)
Paroxysmal AF: AF (≥2 episodes) that terminates spontaneously within 7 days
Persistent AF: >7 days or cardioversion
Longstanding persistent AF: >12 months continuous AF
Permanent AF: AF has been accepted
Heart Rhythm Jun;4(6):

9. HRS/EHRA/ECAS Consensus Statement
Mechanisms of Atrial Fibrillation
YELLOW: 4 major LA autonomic ganglionic plexi and Axons
BLUE: CS + Lig. Marshall (CS LSPV -LAA) which is envelopped by muscle fibers with connections to the Atria
(B) Large and small reentrant wavelets play role in initiation and sustaining AF
(C) Common locations of PVs (red) and common non-PV sites (green)
Heart Rhythm Jun;4(6):

10. AF Ablation Strategies
HRS/EHRA/ECAS Consensus Statement
AF Ablation Strategies
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11. AF Ablation Strategies
Heart Rhythm Jun;4(6):

12. CFAE Definition
Haissaguerre et al. JCE 2005

13. HRS/EHRA/ECAS Consensus Statement
Heart Rhythm Jun;4(6):

14. Procedural Endpoint Wide area circumferential lesions (CCL)
Ouyang et al Circulation
Heart Rhythm. 2007
Wide area circumferential lesions (CCL)
Online Lasso recordings to prove PVI

17. #4 #7 #1 #9
Lateral PVs 17

21. Pulmonary Vein Isolation
LSPV
LIPV
His
Map CS
LSPV
LAA
LIPV
Ouyang F et al. (Circulation 2004;110:2090–2096)

22. * PV LA II V1 PV-lumen Endothel Map PV LA Musclefiber Epicard
Saito et al JCE 2001

23. Indications for AF Catheter Ablation
HRS/EHRA/ECAS Consensus Statement
Indications for AF Catheter Ablation
It is important to recognize that catheter ablation of AF is a demanding technical procedure that may result in complications
Patients should only undergo AF ablation after carefully weighing the risks and benefits of the procedure
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24. Indications for AF Catheter Ablation
HRS/EHRA/ECAS Consensus Statement
Indications for AF Catheter Ablation
Symptomatic AF refractory ≥ 1 AAD (Class I, III)
AF ablation as first line therapy (rare clinical situations)
Selected pts with heart failure and/or reduced EF
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25. Complications in AF Ablation
HRS/EHRA/ECAS Consensus Statement
Complications in AF Ablation
Cardiac tamponade (<6%)
Pulmonary vein stenosis (0-38%)
Atrio-Esophageal fistula (<0.25%)
Phrenic nerve injury (<0.48%)
Thromembolism (0-7%)
Post procedural arrhythmias (5-25%)
Vascular complications (0-13%)
Radiation exposure
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26. Technique / Lab Managements
HRS/EHRA/ECAS Consensus Statement
Technique / Lab Managements
Heparin  Target ACT 300 to 400s
Careful identification of PV ostia is mandatory
If additional lesions are applied, line completeness should be demonstrated
RAI block only in pts with typical or inducible AFL
Non PV triggers should be targeted if possible
If pts with longstanding persistent AF are approached, ostial PVI may not be sufficent
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27. Follow Up / Clinical Trial
HRS/EHRA/ECAS Consensus Statement
Follow Up / Clinical Trial
Blanking period: 3 months when reporting outcomes
Definition of Success:
No AF/AFL/AT off AAD as the primary endpoint
No AF at various points after ablation may be secondary endpoint
AF/AFL/AT >30s are treatment failures
Single procedure success should be reported
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28. HRS/EHRA/ECAS Consensus Statement
Minimal Monitoring
F/U visits; 3 months, 9 months and then every 6 months for at least 2 years
Event monitor in pts who complain of palpitations
AF/AFL/AT >30s are treatment failures
24h HOLTER is acceptable for minimal monitoring for pts in clinical trials and is recommended at 3 to 6 months intervals for 1 to 2 years
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29. Hamburg AF Ablation Approach
1. Procedure: Wide area circumferential PVI of ipsilateral PVs
2. Procedure: Re-check PV conduction: Gap closure
Clinical AT  Ablation
3. Procedure: CFAE identification and ablation (LA, CS, RA)

30. HRS/EHRA/ECAS Consensus Statement
Conclusion
Catheter ablation of AF is...
performed throughout the world
associated with high success rates
significant complications
PV isolation is cornerstone of AF ablation