What is the procedure for atrial fibrillation (AF) ablation?

From the Guidelines

Atrial fibrillation (AF) ablation is a procedure that uses energy to create controlled scarring in heart tissue to block abnormal electrical signals causing AF, and it is typically recommended for patients with symptomatic AF who have failed or cannot tolerate antiarrhythmic medications. The procedure primarily involves pulmonary vein isolation (PVI), as most AF triggers originate from the pulmonary veins 1. Additional ablation targets may include the left atrial posterior wall, superior vena cava, and other areas depending on the type of AF. The success rates range from 60-80% for paroxysmal AF and 50-70% for persistent AF, often requiring multiple procedures 1. The most recent guidelines recommend catheter ablation as an alternative to antiarrhythmic drug therapy for patients with symptomatic recurrent paroxysmal AF on antiarrhythmic drug therapy, provided the procedure is performed by an experienced operator 1. Complications occur in about 2-4% of cases and may include vascular injury, cardiac tamponade, stroke, pulmonary vein stenosis, phrenic nerve injury, and atrio-esophageal fistula. Patients require anticoagulation (warfarin, apixaban, rivaroxaban, dabigatran, or edoxaban) for at least 2-3 months post-procedure, and many continue long-term based on their CHA₂DS₂-VASc score. The mechanism involves creating conduction blocks that prevent abnormal electrical signals from spreading throughout the atria, thereby maintaining normal sinus rhythm. Some key points to consider when performing AF ablation include:

• Catheter ablation is recommended as an alternative to antiarrhythmic drug therapy for patients with symptomatic recurrent paroxysmal AF on antiarrhythmic drug therapy, provided the procedure is performed by an experienced operator 1
• Continuation of oral VKA therapy can be considered throughout the ablation procedure but robust data for NOACs are lacking 1
• In selected patients with paroxysmal AF and no structural heart disease left atrial ablation is reasonable as first-line therapy 1
• Restoration of sinus rhythm after catheter ablation for AF significantly improved LV function, exercise capacity, symptoms, and quality of life, even in the presence of concurrent heart disease and when ventricular rate control was adequate before ablation 1

From the Research

Procedure Overview

The procedure for atrial fibrillation (AF) ablation involves several steps, including:

• Bilateral pulmonary vein isolation
• Mapping and ablation of the ganglionic plexi
• Excision of the left atrial appendage
• Epicardial ablation using various energy sources, such as microwave or radiofrequency 2, 3

Minimally Invasive Approaches

Minimally invasive surgical ablation of AF can be performed through:

• Thoracoscopic approach, using a FLEX 10 AFx Microwave Ablation System 2
• Bilateral minithoracotomies with video assistance 3
• Video-assisted bilateral mini-thoracotomy or thoracoscopic pulmonary vein island creation and left atrial appendage removal or exclusion 4

Hybrid Approach

A hybrid approach has been introduced, which combines a mono or bilateral epicardial approach with a percutaneous endocardial ablation in a single-step procedure to limit the shortcomings of both techniques 4

Key Considerations

• The procedure can be performed on a beating heart, with minimal risk to the patient and a rapid recovery 5, 6
• The ideal procedure would have high cure rates, minimal risk, and a rapid recovery 6
• Continuous event monitoring is necessary to accurately assess treatment results 3