A new global consensus statement on how to treat atrial fibrillation with catheter or surgical ablation has been released by a consortium of international cardiac electrophysiology societies including Australian cardiologists.

The new guidance is the first update in seven years from the group led by the European Heart Rhythm Association and including the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society.

The authors include Professor Jonathan Kalman of the Royal Melbourne Hospital and Professor Prash Sanders of the Centre for Heart Rhythm Disorders, University of Adelaide. They say the rapidly changing evidence base and technological advances since 2017 means that a more up-to-date framework is needed for selection and management of patients considered for or undergoing catheter or surgical AF ablation.

The new consensus statement, published simultaneously in EP Europace (link here)  and other heart rhythm journals, covers areas of AF catheter ablation including  classification, anatomical considerations, indications, risk factors, mapping and ablation tools for AF, procedural management, ablation strategies, postprocedural management, ablation outcome and efficacy, complications, surgical and hybrid AF ablation and training and institutional requirements for AF ablation.

The advice is divided into categories based on evidence such as ‘Advice To Do’, ‘May Be Appropriate’, ‘Area of Uncertainty’ and ‘Advice Not to Do’.

Examples of Advice To Do include: “Catheter ablation of AF is beneficial in symptomatic patients with recurrent paroxysmal or persistent AF resistant or intolerant to previous treatment with at least one Class I or III antiarrhythmic drug.”

An example of May be Appropriate is: Stand-alone surgical or hybrid ablation is reasonable in symptomatic patients with persistent AF with prior unsuccessful catheter ablation and also in those who are intolerant or refractory to antiarrhythmic drug therapy and prefer a surgical/hybrid approach, after careful consideration of relative safety and efficacy of treatment options.

An area of uncertainty identified in the guidance is “Catheter ablation of AF may be reasonable in selected asymptomatic patients with recurrent paroxysmal or persistent AF following thorough discussion of potential risks and associated benefits.

The only statement of Advice Not to Do is: “Ablation of MRI-detected atrial delayed enhancement areas is not beneficial during persistent AF ablation.

Best practice standards

Lead author Dr Stylianos Tzeis, a cardiologist in Athens, Greece, said the comprehensive document covered best practice standards and practical advice on a range of issues from how to select patients, preprocedural considerations and how to follow up patients after ablation.

He said the statement advises that catheter ablation is beneficial as first-line treatment in patients with symptoms and recurrent atrial fibrillation. It is also beneficial in symptomatic patients with recurrent paroxysmal or persistent atrial fibrillation who are resistant or intolerant to at least one antiarrhythmic drug.

The statement advises that all patients should receive anticoagulation for at least two months after the AF ablation procedure, and prolonged anticoagulation may be required depending on the risk of blood clots.

Antiarrhythmic drugs are advised for some patients to prevent arrhythmia recurrences early after the procedure.

While complications following catheter ablation are uncommon they can include stroke, pericardial tamponade, TIA and vascular complications at the access site in the groin. The risk of death is extremely low (0.05-0.1%).

“Ablation is the most effective way to prevent recurrences of atrial fibrillation and delay progression to more advanced forms. Pioneering techniques have emerged since the previous consensus in 2017, requiring new advice on who should receive this procedure and how to perform it in the safest and most effective manner,” he said.

“Technological innovations have made catheter ablation safer and more effective than ever before. For example, we now have pulsed field ablation which uses high energy electrical pulses to treat atrial fibrillation without damaging the nerves or oesophagus. We can also use intracardiac echocardiography to guide and facilitate the procedure with real-time visualisation of the cardiac structures being treated,” Dr Tzeis added.

The document also highlight areas for future research in AF ablation, with several key unanswered questions such as:

• Can we develop a personalised approach to AF ablation based on risk factors, AF duration, and atrial substrate?
• Do asymptomatic individuals benefit from catheter ablation, including reductions in cardiovascular adverse events?
• What are the optimal settings for cryothermy and radiofrequency ablation in different LA regions?
• Can combined pulsed field and thermal ablation modalities improve AF ablation efficacy and safety?
• What is the optimal ablation approach of persistent AF?
• Can we reproducibly map focal AF drivers and does ablation of these focal sources lead to improved outcomes?
• Which patients benefit from hybrid ablation? Are outcomes and safety improved compared with catheter ablation?