When should catheter ablation (CA) be performed for atrial fibrillation (AFib)?

From the Guidelines

Catheter ablation for atrial fibrillation should be considered as a first-line rhythm control therapy in selected patients with symptomatic paroxysmal AF episodes, as recommended by the 2024 ESC guidelines 1.

Key Considerations

• The decision to perform catheter ablation should be made within a shared decision-making rhythm control strategy, taking into account the patient's symptoms, preferences, and risk factors for recurrence.
• Patients with paroxysmal AF who have failed medical therapy or cannot tolerate antiarrhythmic medications due to side effects may benefit from catheter ablation, with success rates ranging from 70-80% 1.
• Before proceeding with ablation, patients should undergo cardiac imaging (typically echocardiography) to assess for structural heart disease and left atrial size, as well as screening for reversible causes of atrial fibrillation such as hyperthyroidism or sleep apnea.

Procedure and Outcomes

• The procedure involves creating lesions around the pulmonary veins to electrically isolate them from the left atrium, as these veins are common sources of the electrical triggers that initiate atrial fibrillation.
• Patients should understand that ablation is not always curative, and approximately 20-40% may require a second procedure for optimal results, particularly those with persistent atrial fibrillation.

Alternative Options

• Thoracoscopic procedures, including hybrid surgical ablation, may be considered in patients who have symptomatic paroxysmal or persistent AF refractory to AAD therapy and have failed percutaneous AF ablation, or with evident risk factors for catheter ablation failure 1.
• Concomitant AF ablation should be considered in patients undergoing cardiac surgery, balancing the benefits of freedom from atrial arrhythmias and the risk factors for recurrence.

From the Research

Indications for Catheter Ablation in Atrial Fibrillation

Catheter ablation (CA) is considered a treatment option for atrial fibrillation (AFib) in certain patient populations. The decision to perform CA should be based on individual patient characteristics and symptoms.

• CA is recommended as a second-line therapy for patients with symptomatic paroxysmal or persistent AFib who have failed or are intolerant to pharmacological therapy 2.
• In selected patients with heart failure and reduced left-ventricular fraction, CA has been shown to reduce all-cause mortality 2.
• CA may be considered as a first-line therapy for AFib in certain patients, particularly those with symptomatic paroxysmal or persistent AFib who are at high risk of stroke or have significant symptoms despite antiarrhythmic drug therapy 3, 2, 4.

Patient Selection for Catheter Ablation

The selection of patients for CA should be based on a comprehensive evaluation of their symptoms, medical history, and comorbidities.

• Patients with highly symptomatic AFib who have failed or are intolerant to pharmacological therapy may be good candidates for CA 5, 6.
• Patients with heart failure and reduced left-ventricular fraction may also benefit from CA 2.
• The presence of comorbidities such as hypertension, diabetes, and obstructive sleep apnea should be taken into account when selecting patients for CA, as optimal management of these conditions can reduce AFib recurrence after CA 2.

Timing of Catheter Ablation

The timing of CA should be individualized based on patient characteristics and symptoms.

• CA may be considered as a first-line therapy for AFib in certain patients, particularly those with symptomatic paroxysmal or persistent AFib who are at high risk of stroke or have significant symptoms despite antiarrhythmic drug therapy 3, 2, 4.
• In other patients, CA may be considered as a second-line therapy after failure or intolerance to pharmacological therapy 2.