2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

Abstract

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Keywords: Atrial fibrillation; Catheter ablation; Surgical ablation.

Figure 1

Pathophysiological mechanisms of atrial fibrillation. APD, action potential duration; CV, conduction velocity; DADs, delayed afterdepolarizations; EADs, early afterdepolarizations; RP, refractory period; RyR, ryanodine receptor; SERCA, sarcoplasmic/endoplasmic reticulum Ca²⁺-ATPase.

Figure 2

Typical PV anatomy and common variants. PV, pulmonary vein.

Figure 3

(A) Anatomy of interatrial septum and optimal site of transseptal puncture (demarcated with a brace). Black arrow in the dotted area shows the infolded groove of the atrial wall between the SVC and the right PVs filled with extracardiac fat tissue. (B) Intracardiac echo view of typical tenting before transseptal crossing. Modified from Tzeis et al. IVC, inferior vena cava; LIVP, left inferior pulmonary vein; LSVP, left superior pulmonary vein; PV, pulmonary vein; RIVP, right inferior pulmonary vein; RSVP, right superior pulmonary vein; SVC, superior vena cava

Figure 4

Anatomic variations of the interatrial septum that may be encountered during transseptal puncture. (A) Patent foramen ovale (white arrow); (B) septal aneurysm with large excursion towards the right atrium (white arrow); (C) tenting of floppy septum from transseptal needle close to the left atrial wall; (D) very small fossa ovalis (white arrow) in a patient with lipomatous septal hypertrophy (yellow arrow); (E) standard transseptal needle crossing a pericardial patch; (F) atrial septal closure device (yellow arrow) covering almost all of the interatrial septum. LA, left atrium.

Figure 5

Architecture of atrial musculature. Upper left: main atrial muscular bundles from anterior view. Lower left: transection of the Bachmann's bundle, postero-superior interatrial bundle, and the septopulmonary bundle enables visualization of the septoatrial bundle. Upper right: main atrial muscular bundles from posterior view with slight rightward tilting—the stars denote epicardial connections of the right PVs with the right atrium and left atrium posterior wall. Lower right: transection of the septopulmonary bundle coursing epicardially enables visualization of the septoatrial bundle and neighbouring fat inter-position. PV, pulmonary vein.

Figure 6

Course of the right phrenic nerve in relation to neighbouring structures in different projections (A: right anterior oblique; B: right lateral; C: right posterior oblique)—reconstruction from computed tomography scan. IVC, inferior vena cava; LA, left atrium; RA, right atrium; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein; SVC, superior vena cava.

Figure 7

Suggested advice for catheter ablation in patients with paroxysmal or persistent AF in relation to the presence of AF-related symptoms. AAD, antiarrhythmic drug; AF, atrial fibrillation.

Figure 8

Risk factors and respective targets for AF prevention in patients considered for or undergoing AF ablation—the HEAD2TOES schema (green light: established evidence; orange light: evolving evidence). AF, atrial fibrillation; AHI, apnoea–hypopnoea index; BMI, body mass index; CPAP, continuous positive airway pressure; HbA1c, glycated haemoglobin; HTN, hypertension.

Figure 9

Multielectrode mapping catheters.

Figure 10

Prevention, clinical presentation investigation, and management of atrio-oesophageal fistula. CF, contact force; CT, computed tomography; ICE, intracardiac echocardiography; LGE, late gadoliniun enhancement; MRI, magnetic resonance imaging; PPI, proton pump inhibitor; RF, radiofrequency; TIA, transient ischemic attack.

Figure 11

Prevention, clinical presentation, investigation, and management of transient ischemic attack/stroke in the postablation setting. ACT, activated clotting time; CT, computed tomography; ICE, intracardiac echocardiography; MRI, magnetic resonance imaging; OAC, oral anticoagulant; TIA, transient ischemic attack; TSP, transseptal puncture.

Figure 12

Prevention, clinical presentation, investigation, and management of periprocedural cardiac tamponade. ICE, intracardiac echocardiography; RF, radiofrequency; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.

Figure 13

Prevention, clinical presentation, investigation, and management of phrenic nerve palsy. CMAP, compound motor action potential; PV, pulmonary vein; w/wo, with or without.

Figure 14

Lesion sets of the Cox maze IV procedure. (A) Left atrial lesion set including: (i) left atriotomy, (ii) ablation around the left-sided PVs, (iii) ablation around the right-sided PVs, (iv) posterior wall box lesion, (v) line connecting left PV lesion to excluded LAA, (vi) line connecting box lesion to mitral annulus, (vii) cryoablation to the epicardial ostial region of the coronary sinus (not shown). (B) Right atrial lesion set including: (i) right atriotomy extending over crista terminalis, (ii) line from the atriotomy to the superior and inferior vena cava posterior to the crista terminalis (to avoid injury to the sinoatrial node), (iii) line connecting the atriotomy to the tricuspid annulus (2 o’ clock relative to the valve), and (iv) line connecting the right atriotomy to the right atrial appendage. LAA, left atrial appendage; PV, pulmonary vein.

Figure 15

Posterior view of the left atrium showing epicardial lesion sets during thoracoscopic surgical AF ablation: pulmonary vein isolation with connecting roof and inferior lines (A), en-bloc pulmonary vein and posterior wall isolation using the Cardioblate Gemini-S (Medtronic Inc.) RF ablation system (B), and posterior wall ablation using the convergent approach (C). AF, atrial fibrillation; RF, radiofrequency.