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2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary

Open AccessPublished:September 15, 2017DOI:https://doi.org/10.1016/j.hrthm.2017.07.009

      Keywords

      Abbreviations:

      AAD (antiarrhythmic drug), AF (atrial fibrillation), AFL (atrial flutter), CB (cryoballoon), CFAE (complex fractionated atrial electrogram), LA (left atrial), LAA (left atrial appendage), LGE (late gadolinium-enhanced), LOE (level of evidence), MRI (magnetic resonance imaging), OAC (oral anticoagulation), RF (radiofrequency)

      Section 1: Introduction

      During the past three decades, catheter and surgical ablation of atrial fibrillation (AF) have evolved from investigational procedures to their current role as effective treatment options for patients with AF. Surgical ablation of AF, using either standard, minimally invasive, or hybrid techniques, is available in most major hospitals throughout the world. Catheter ablation of AF is even more widely available, and is now the most commonly performed catheter ablation procedure.
      In 2007, an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA), and the European Cardiac Arrhythmia Society (ECAS).
      • Calkins H.
      • et al.
      HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation.
      The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC). This Consensus Statement on Catheter and Surgical AF Ablation was rewritten in 2012 to reflect the many advances in AF ablation that had occurred in the interim.
      • Calkins H.
      • et al.
      2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design.
      The rate of advancement in the tools, techniques, and outcomes of AF ablation continue to increase as enormous research efforts are focused on the mechanisms, outcomes, and treatment of AF. For this reason, the HRS initiated an effort to rewrite and update this Consensus Statement. Reflecting both the worldwide importance of AF, as well as the worldwide performance of AF ablation, this document is the result of a joint partnership between the HRS, EHRA, ECAS, the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología [SOLAECE]). The purpose of this 2017 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a writing group, convened by these five international societies. The writing group is charged with defining the indications, techniques, and outcomes of AF ablation procedures. Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes, including definitions relevant to this topic.
      The writing group is composed of 60 experts representing 11 organizations: HRS, EHRA, ECAS, APHRS, SOLAECE, STS, ACC, American Heart Association (AHA), Canadian Heart Rhythm Society (CHRS), Japanese Heart Rhythm Society (JHRS), and Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardíacas [SOBRAC]). All the members of the writing group, as well as peer reviewers of the document, have provided disclosure statements for all relationships that might be perceived as real or potential conflicts of interest. All author and peer reviewer disclosure information is provided in Appendix A and Appendix B.
      In writing a consensus document, it is recognized that consensus does not mean that there was complete agreement among all the writing group members. Surveys of the entire writing group were used to identify areas of consensus concerning performance of AF ablation procedures and to develop recommendations concerning the indications for catheter and surgical AF ablation. These recommendations were systematically balloted by the 60 writing group members and were approved by a minimum of 80% of these members. The recommendations were also subject to a 1-month public comment period. Each partnering and collaborating organization then officially reviewed, commented on, edited, and endorsed the final document and recommendations.
      The grading system for indication of class of evidence level was adapted based on that used by the ACC and the AHA.
      • Jacobs A.K.
      • Anderson J.L.
      • Halperin J.L.
      The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
      • Anderson J.L.
      Evolution of the ACC/AHA clinical practice guidelines in perspective: guiding the guidelines.
      It is important to state, however, that this document is not a guideline. The indications for catheter and surgical ablation of AF, as well as recommendations for procedure performance, are presented with a Class and Level of Evidence (LOE) to be consistent with what the reader is familiar with seeing in guideline statements. A Class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks, and that AF ablation should be performed; a Class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks, and that it is reasonable to perform AF ablation; a Class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks, and that AF ablation may be considered; and a Class III recommendation means that AF ablation is of no proven benefit and is not recommended.
      The writing group reviewed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from high-quality evidence from more than one randomized clinical trial, meta-analyses of high-quality randomized clinical trials, or one or more randomized clinical trials corroborated by high-quality registry studies. The writing group ranked available evidence as Level B-R when there was moderate-quality evidence from one or more randomized clinical trials, or meta-analyses of moderate-quality randomized clinical trials. Level B-NR was used to denote moderate-quality evidence from one or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies. This designation was also used to denote moderate-quality evidence from meta-analyses of such studies. Evidence was ranked as Level C-LD when the primary source of the recommendation was randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological or mechanistic studies of human subjects. Level C-EO was defined as expert opinion based on the clinical experience of the writing group.
      Despite a large number of authors, the participation of several societies and professional organizations, and the attempts of the group to reflect the current knowledge in the field adequately, this document is not intended as a guideline. Rather, the group would like to refer to the current guidelines on AF management for the purpose of guiding overall AF management strategies.
      • January C.T.
      • et al.
      2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
      • Kirchhof P.
      • et al.
      2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
      This consensus document is specifically focused on catheter and surgical ablation of AF, and summarizes the opinion of the writing group members based on an extensive literature review as well as their own experience. It is directed to all health care professionals who are involved in the care of patients with AF, particularly those who are caring for patients who are undergoing, or are being considered for, catheter or surgical ablation procedures for AF, and those involved in research in the field of AF ablation. This statement is not intended to recommend or promote catheter or surgical ablation of AF. Rather, the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient.
      The main objective of this document is to improve patient care by providing a foundation of knowledge for those involved with catheter ablation of AF. A second major objective is to provide recommendations for designing clinical trials and reporting outcomes of clinical trials of AF ablation. It is recognized that this field continues to evolve rapidly. As this document was being prepared, further clinical trials of catheter and surgical ablation of AF were under way.

      Section 2: Definitions, Mechanisms, and Rationale for AF Ablation

      This section of the document provides definitions for use in the diagnosis of AF. This section also provides an in-depth review of the mechanisms of AF and rationale for catheter and surgical AF ablation (Table 1, Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6).
      Table 1Atrial fibrillation definitions
      AF episodeAn AF episode is defined as AF that is documented by ECG monitoring or intracardiac electrogram monitoring and has a duration of at least 30 seconds, or if less than 30 seconds, is present throughout the ECG monitoring tracing. The presence of subsequent episodes of AF requires that sinus rhythm be documented by ECG monitoring between AF episodes.
      Chronic AFChronic AF has variable definitions and should not be used to describe populations of AF patients undergoing AF ablation.
      Early persistent AFEarly persistent AF is defined as AF that is sustained beyond 7 days but is less than 3 months in duration.
      Lone AFLone AF is a historical descriptor that is potentially confusing and should not be used to describe populations of patients with AF undergoing AF ablation.
      Long-standing persistent AFLong-standing persistent AF is defined as continuous AF of greater than 12 months’ duration.
      Paroxysmal AFParoxysmal AF is defined as AF that terminates spontaneously or with intervention within 7 days of onset.
      Permanent AFPermanent AF is defined as the presence of AF that is accepted by the patient and physician, and for which no further attempts to restore or maintain sinus rhythm will be undertaken. The term permanent AF represents a therapeutic attitude on the part of the patient and physician rather than an inherent pathophysiological attribute of AF. The term permanent AF should not be used within the context of a rhythm control strategy with antiarrhythmic drug therapy or AF ablation.
      Persistent AFPersistent AF is defined as continuous AF that is sustained beyond 7 days.
      Silent AFSilent AF is defined as asymptomatic AF diagnosed with an opportune ECG or rhythm strip.
      AF = atrial fibrillation; ECG = electrocardiogram.
      Figure thumbnail gr1
      Figure 1Anatomical drawings of the heart relevant to AF ablation. This series of drawings shows the heart and associated relevant structures from four different perspectives relevant to AF ablation. This drawing includes the phrenic nerves and the esophagus. A: The heart viewed from the anterior perspective. B: The heart viewed from the right lateral perspective. C: The heart viewed from the left lateral perspective. D: The heart viewed from the posterior perspective. E: The left atrium viewed from the posterior perspective.
      Illustration: Tim Phelps © 2017 Johns Hopkins University, AAM.
      Figure thumbnail gr2
      Figure 2This figure includes six CT or MR images of the left atrium and pulmonary veins viewed from the posterior perspective. Common and uncommon variations in PV anatomy are shown. A: Standard PV anatomy with 4 distinct PV ostia. B: Variant PV anatomy with a right common and a left common PV. C: Variant PV anatomy with a left common PV with a short trunk and an anomolous PV arising from the right posterior left atrial wall. D and E: Variant PV anatomy with a common left PV with a long trunk. F: Variant PV anatomy with a massive left common PV.
      Figure thumbnail gr3
      Figure 3Schematic drawing showing various hypotheses and proposals concerning the mechanisms of atrial fibrillation. A: Multiple wavelets hypothesis. B: Rapidly discharging automatic foci. C: Single reentrant circuit with fibrillatory conduction. D: Functional reentry resulting from rotors or spiral waves. E: AF maintenance resulting from dissociation between epicardial and endocardial layers, with mutual interaction producing multiplying activity that maintains the arrhythmia.
      Figure thumbnail gr4
      Figure 4Structure and mechanisms of atrial fibrillation. A: Schematic drawing of the left and right atria as viewed from the posterior perspective. The extension of muscular fibers onto the PVs can be appreciated. Shown in yellow are the five major left atrial autonomic ganglionic plexi (GP) and axons (superior left GP, inferior left GP, anterior right GP, inferior right GP, and ligament of Marshall). Shown in blue is the coronary sinus, which is enveloped by muscular fibers that have connections to the atria. Also shown in blue is the vein and ligament of Marshall, which travels from the coronary sinus to the region between the left superior PV and the left atrial appendage. B: The large and small reentrant wavelets that play a role in initiating and sustaining AF. C: The common locations of PV (red) and also the common sites of origin of non-PV triggers (shown in green). D: Composite of the anatomic and arrhythmic mechanisms of AF.
      Adapted with permission from Calkins et al. Heart Rhythm 2012; 9:632–696.e21.
      • Calkins H.
      • et al.
      2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design.
      Figure thumbnail gr5
      Figure 5Schematic drawing showing mechanisms of atrial flutter and atrial tachycardia. A: Isthmus-dependent reverse common (clockwise) atrial flutter. B: Isthmus-dependent common (counter clockwise) atrial flutter. C: Focal atrial tachycardia with circumferential spread of activation of the atria (can arise from multiple sites within the left and right atrium). D: Microreentrant atrial tachycardia with circumferential spread of activation of the atria. E: Perimitral atrial flutter. F: Roof-dependent atrial flutter.
      Figure thumbnail gr6
      Figure 6Schematic of common lesion sets employed in AF ablation. A: The circumferential ablation lesions that are created in a circumferential fashion around the right and the left PVs. The primary endpoint of this ablation strategy is the electrical isolation of the PV musculature. B: Some of the most common sites of linear ablation lesions. These include a “roof line” connecting the lesions encircling the left and/or right PVs, a “mitral isthmus” line connecting the mitral valve and the lesion encircling the left PVs at the end of the left inferior PV, and an anterior linear lesion connecting either the “roof line” or the left or right circumferential lesion to the mitral annulus anteriorly. A linear lesion created at the cavotricuspid isthmus is also shown. This lesion is generally placed in patients who have experienced cavotricuspid isthmus-dependent atrial flutter clinically or have it induced during EP testing. C: Similar to 6B, but also shows additional linear ablation lesions between the superior and inferior PVs resulting in a figure of eight lesion sets as well as a posterior inferior line allowing for electrical isolation of the posterior left atrial wall. An encircling lesion of the superior vena cava (SVC) directed at electrical isolation of the SVC is also shown. SVC isolation is performed if focal firing from the SVC can be demonstrated. A subset of operators empirically isolates the SVC. D: Representative sites for ablation when targeting rotational activity or CFAEs are targeted.
      Modified with permission from Calkins et al. Heart Rhythm 2012; 9:632–696.e21.
      • Calkins H.
      • et al.
      2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design.

      Section 3: Modifiable Risk Factors for AF and Impact on Ablation

      Management of patients with AF has traditionally consisted of three main components: (1) anticoagulation for stroke prevention; (2) rate control; and (3) rhythm control. With the emergence of large amounts of data, which have both defined and called attention to the interaction between modifiable risk factors and the development of AF and outcomes of AF management, we believe it is time to include risk factor modification as the fourth pillar of AF management. This section of the document reviews the link between modifiable risk factors and both the development of AF and their impacts on the outcomes of AF ablation.

      Section 4: Indications

      Shown in Table 2, and summarized in Figures 7 and 8 of this document, are the Consensus Indications for Catheter and Surgical Ablation of AF. As outlined in the introduction section of this document, these indications are stratified as Class I, Class IIa, Class IIb, and Class III indications. The evidence supporting these indications is provided, as well as a selection of the key references supporting these levels of evidence. In making these recommendations, the writing group considered the body of published literature that has defined the safety and efficacy of catheter and surgical ablation of AF. Also considered in these recommendations is the personal lifetime experience in the field of each of the writing group members. Both the number of clinical trials and the quality of these trials were considered. In considering the class of indications recommended by this writing group, it is important to keep several points in mind. First, these classes of indications only define the indications for catheter and surgical ablation of AF when performed by an electrophysiologist or a surgeon who has received appropriate training and/or who has a certain level of experience and is performing the procedure in an experienced center (Section 11). Catheter and surgical ablation of AF are highly complex procedures, and a careful assessment of the benefit and risk must be considered for each patient. Second, these indications stratify patients based only on the type of AF and whether the procedure is being performed prior to or following a trial of one or more Class I or III antiarrhythmic medications. This document for the first time includes indications for catheter ablation of select asymptomatic patients. As detailed in Section 9, there are many other additional clinical and imaging-based variables that can be used to further define the efficacy and risk of ablation in a given patient. Some of the variables that can be used to define patients in whom a lower success rate or a higher complication rate can be expected include the presence of concomitant heart disease, obesity, sleep apnea, left atrial (LA) size, patient age and frailty, as well as the duration of time the patient has been in continuous AF. Each of these variables needs to be considered when discussing the risks and benefits of AF ablation with a particular patient. In the presence of substantial risk or anticipated difficulty of ablation, it could be more appropriate to use additional antiarrhythmic drug (AAD) options, even if the patient on face value might present with a Class I or IIa indication for ablation. Third, it is important to consider patient preference and values. Some patients are reluctant to consider a major procedure or surgery and have a strong preference for a pharmacological approach. In these patients, trials of antiarrhythmic agents including amiodarone might be preferred to catheter ablation. On the other hand, some patients prefer a nonpharmacological approach. Fourth, it is important to recognize that some patients early in the course of their AF journey might have only infrequent episodes for many years and/or could have AF that is responsive to well-tolerated AAD therapy. And finally, it is important to bear in mind that a decision to perform catheter or surgical AF ablation should only be made after a patient carefully considers the risks, benefits, and alternatives to the procedure.
      Table 2Indications for catheter (A and B) and surgical (C, D, and E) ablation of atrial fibrillation
      RecommendationClassLOEReferences
      Indications for catheter ablation of atrial fibrillation
      A. Indications for catheter ablation of atrial fibrillation
      Symptomatic AF refractory or intolerant to at least one Class I or III antiarrhythmic medicationParoxysmal: Catheter ablation is recommended.IA
      • Jais P.
      • et al.
      Catheter ablation versus antiarrhythmic drugs for atrial fibrillation: the A4 study.
      • Calkins H.
      • et al.
      Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses.
      • Packer D.L.
      • et al.
      Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) pivotal trial.
      • Kuck K.H.
      • et al.
      Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation.
      • Dukkipati S.R.
      • et al.
      Pulmonary vein isolation using the visually guided laser balloon: a prospective, multicenter, and randomized comparison to standard radiofrequency ablation.
      • Reddy V.Y.
      • et al.
      Randomized, controlled trial of the safety and effectiveness of a contact force-sensing irrigated catheter for ablation of paroxysmal atrial fibrillation: results of the TactiCath Contact Force Ablation Catheter Study for Atrial Fibrillation (TOCCASTAR) study.
      • Natale A.
      • et al.
      Paroxysmal AF catheter ablation with a contact force sensing catheter: results of the prospective, multicenter SMART-AF trial.
      • Wilber D.J.
      • et al.
      Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial.
      • Sohara H.
      • et al.
      HotBalloon ablation of the pulmonary veins for paroxysmal AF: a multicenter randomized trial in Japan.
      • Pappone C.
      • et al.
      A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF Study.
      • Stabile G.
      • et al.
      Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multi-centre, randomized, controlled study (Catheter Ablation For The Cure Of Atrial Fibrillation Study).
      • Forleo G.B.
      • et al.
      Catheter ablation of atrial fibrillation in patients with diabetes mellitus type 2: results from a randomized study comparing pulmonary vein isolation versus antiarrhythmic drug therapy.
      Persistent: Catheter ablation is reasonable.IIaB-NR
      • Calkins H.
      • et al.
      Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses.
      • Pappone C.
      • et al.
      A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF Study.
      • Stabile G.
      • et al.
      Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multi-centre, randomized, controlled study (Catheter Ablation For The Cure Of Atrial Fibrillation Study).
      • Forleo G.B.
      • et al.
      Catheter ablation of atrial fibrillation in patients with diabetes mellitus type 2: results from a randomized study comparing pulmonary vein isolation versus antiarrhythmic drug therapy.
      • Verma A.
      • et al.
      Approaches to catheter ablation for persistent atrial fibrillation.
      • Scherr D.
      • et al.
      Five-year outcome of catheter ablation of persistent atrial fibrillation using termination of atrial fibrillation as a procedural endpoint.
      • Tamborero D.
      • et al.
      Left atrial posterior wall isolation does not improve the outcome of circumferential pulmonary vein ablation for atrial fibrillation: a prospective randomized study.
      • Hummel J.
      • et al.
      Phased RF ablation in persistent atrial fibrillation.
      • Bassiouny M.
      • et al.
      Randomized study of persistent atrial fibrillation ablation: ablate in sinus rhythm versus ablate complex-fractionated atrial electrograms in atrial fibrillation.
      • Krittayaphong R.
      • et al.
      A randomized clinical trial of the efficacy of radiofrequency catheter ablation and amiodarone in the treatment of symptomatic atrial fibrillation.
      • Oral H.
      • et al.
      Circumferential pulmonary-vein ablation for chronic atrial fibrillation.
      • Mont L.
      • et al.
      Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study).
      Long-standing persistent: Catheter ablation may be considered.IIbC-LD
      • Calkins H.
      • et al.
      Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses.
      • Pappone C.
      • et al.
      A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF Study.
      • Stabile G.
      • et al.
      Catheter ablation treatment in patients with drug-refractory atrial fibrillation: a prospective, multi-centre, randomized, controlled study (Catheter Ablation For The Cure Of Atrial Fibrillation Study).
      • Forleo G.B.
      • et al.
      Catheter ablation of atrial fibrillation in patients with diabetes mellitus type 2: results from a randomized study comparing pulmonary vein isolation versus antiarrhythmic drug therapy.
      • Verma A.
      • et al.
      Approaches to catheter ablation for persistent atrial fibrillation.
      • Scherr D.
      • et al.
      Five-year outcome of catheter ablation of persistent atrial fibrillation using termination of atrial fibrillation as a procedural endpoint.
      • Tamborero D.
      • et al.
      Left atrial posterior wall isolation does not improve the outcome of circumferential pulmonary vein ablation for atrial fibrillation: a prospective randomized study.
      • Hummel J.
      • et al.
      Phased RF ablation in persistent atrial fibrillation.
      • Bassiouny M.
      • et al.
      Randomized study of persistent atrial fibrillation ablation: ablate in sinus rhythm versus ablate complex-fractionated atrial electrograms in atrial fibrillation.
      • Krittayaphong R.
      • et al.
      A randomized clinical trial of the efficacy of radiofrequency catheter ablation and amiodarone in the treatment of symptomatic atrial fibrillation.
      • Oral H.
      • et al.
      Circumferential pulmonary-vein ablation for chronic atrial fibrillation.
      • Mont L.
      • et al.
      Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study).
      Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class I or III antiarrhythmic medicationParoxysmal: Catheter ablation is reasonable.IIaB-R
      • Calvo N.
      • et al.
      Efficacy of circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes.
      • Furlanello F.
      • et al.
      Radiofrequency catheter ablation of atrial fibrillation in athletes referred for disabling symptoms preventing usual training schedule and sport competition.
      • Wazni O.M.
      • et al.
      Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial.
      • Cosedis Nielsen J.
      • et al.
      Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation.
      • Morillo C.A.
      • et al.
      Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial.
      • Hakalahti A.
      • et al.
      Radiofrequency ablation vs antiarrhythmic drug therapy as first line treatment of symptomatic atrial fibrillation: systematic review and meta-analysis.
      • Hocini M.
      • et al.
      Reverse remodeling of sinus node function after catheter ablation of atrial fibrillation in patients with prolonged sinus pauses.
      • Chen Y.W.
      • et al.
      Pacing or ablation: which is better for paroxysmal atrial fibrillation-related tachycardia-bradycardia syndrome?.
      • Inada K.
      • et al.
      The role of successful catheter ablation in patients with paroxysmal atrial fibrillation and prolonged sinus pauses: outcome during a 5-year follow-up.
      Persistent: Catheter ablation is reasonable.IIaC-EO
      Long-standing persistent: Catheter ablation may be considered.IIbC-EO
      B. Indications for catheter atrial fibrillation ablation in populations of patients not well represented in clinical trials
      Congestive heart failureIt is reasonable to use similar indications for AF ablation in selected patients with heart failure as in patients without heart failure.IIaB-R
      • Chen M.S.
      • et al.
      Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function.
      • Gentlesk P.J.
      • et al.
      Reversal of left ventricular dysfunction following ablation of atrial fibrillation.
      • Khan M.N.
      • et al.
      Pulmonary-vein isolation for atrial fibrillation in patients with HF.
      • MacDonald M.R.
      • et al.
      Radiofrequency ablation for persistent atrial fibrillation in patients with advanced heart failure and severe left ventricular systolic dysfunction: a randomised controlled trial.
      • Hunter R.J.
      • et al.
      A randomized controlled trial of catheter ablation versus medical treatment of atrial fibrillation in heart failure (the CAMTAF trial).
      • Tondo C.
      • et al.
      Pulmonary vein vestibule ablation for the control of atrial fibrillation in patients with impaired left ventricular function.
      • Lutomsky B.A.
      • et al.
      Catheter ablation of paroxysmal atrial fibrillation improves cardiac function: a prospective study on the impact of atrial fibrillation ablation on left ventricular function assessed by magnetic resonance imaging.
      • Choi A.D.
      • et al.
      Ablation vs medical therapy in the setting of symptomatic atrial fibrillation and left ventricular dysfunction.
      • De Potter T.
      • et al.
      Left ventricular systolic dysfunction by itself does not influence outcome of atrial fibrillation ablation.
      • Cha Y.M.
      • et al.
      Success of ablation for atrial fibrillation in isolated left ventricular diastolic dysfunction: a comparison to systolic dysfunction and normal ventricular function.
      • Jones D.G.
      • et al.
      A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in HF.
      • Machino-Ohtsuka T.
      • et al.
      Efficacy, safety, and outcomes of catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction.
      • Al Halabi S.
      • et al.
      Catheter ablation for atrial fibrillation in heart failure patients: a meta-analysis of randomized controlled trials.
      • Bunch T.J.
      • et al.
      Five-year outcomes of catheter ablation in patients with atrial fibrillation and left ventricular systolic dysfunction.
      • Lobo T.J.
      • et al.
      Atrial fibrillation ablation in systolic dysfunction: clinical and echocardiographic outcomes.
      • Ling L.H.
      • et al.
      Sinus rhythm restores ventricular function in patients with cardiomyopathy and no late gadolinium enhancement on cardiac magnetic resonance imaging who undergo catheter ablation for atrial fibrillation.
      • Hsu L.F.
      • et al.
      Catheter ablation for atrial fibrillation in congestive HF.
      Older patients (>75 years of age)It is reasonable to use similar indications for AF ablation in selected older patients with AF as in younger patients.IIaB-NR
      • Spragg D.D.
      • et al.
      Complications of catheter ablation for atrial fibrillation: incidence and predictors.
      • Kusumoto F.
      • et al.
      Radiofrequency catheter ablation of atrial fibrillation in older patients: outcomes and complications.
      • Bunch T.J.
      • et al.
      Long-term clinical efficacy and risk of catheter ablation for atrial fibrillation in octogenarians.
      • Santangeli P.
      • et al.
      Catheter ablation of atrial fibrillation in octogenarians: safety and outcomes.
      • Nademanee K.
      • et al.
      Benefits and risks of catheter ablation in elderly patients with atrial fibrillation.
      • Bunch T.J.
      • et al.
      The impact of age on 5-year outcomes after atrial fibrillation catheter ablation.
      • Metzner I.
      • et al.
      Ablation of atrial fibrillation in patients >/=75 years: long-term clinical outcome and safety.
      Hypertrophic cardiomyopathyIt is reasonable to use similar indications for AF ablation in selected patients with HCM as in patients without HCM.IIaB-NR
      • Bunch T.J.
      • et al.
      Substrate and procedural predictors of outcomes after catheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy.
      • Olivotto I.
      • et al.
      Impact of atrial fibrillation on the clinical course of hypertrophic cardiomyopathy.
      • Providencia R.
      • et al.
      Catheter ablation for atrial fibrillation in hypertrophic cardiomyopathy: a systematic review and meta-analysis.
      Young patients (<45 years of age)It is reasonable to use similar indications for AF ablation in young patients with AF (<45 years of age) as in older patients.IIaB-NR
      • Leong-Sit P.
      • et al.
      Efficacy and risk of atrial fibrillation ablation before 45 years of age.
      • Chun K.R.
      • et al.
      Catheter ablation of atrial fibrillation in the young: insights from the German Ablation Registry.
      Tachy-brady syndromeIt is reasonable to offer AF ablation as an alternative to pacemaker implantation in patients with tachy-brady syndrome.IIaB-NR
      • Hocini M.
      • et al.
      Reverse remodeling of sinus node function after catheter ablation of atrial fibrillation in patients with prolonged sinus pauses.
      • Chen Y.W.
      • et al.
      Pacing or ablation: which is better for paroxysmal atrial fibrillation-related tachycardia-bradycardia syndrome?.
      • Inada K.
      • et al.
      The role of successful catheter ablation in patients with paroxysmal atrial fibrillation and prolonged sinus pauses: outcome during a 5-year follow-up.
      Athletes with AFIt is reasonable to offer high-level athletes AF as first-line therapy due to the negative effects of medications on athletic performance.IIaC-LD
      • Calvo N.
      • et al.
      Efficacy of circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes.
      • Furlanello F.
      • et al.
      Radiofrequency catheter ablation of atrial fibrillation in athletes referred for disabling symptoms preventing usual training schedule and sport competition.
      • Koopman P.
      • et al.
      Efficacy of radiofrequency catheter ablation in athletes with atrial fibrillation.
      Asymptomatic AF
      A decision to perform AF ablation in an asymptomatic patient requires additional discussion with the patient because the potential benefits of the procedure for the patient without symptoms are uncertain.
      Paroxysmal: Catheter ablation may be considered in select patients.
      A decision to perform AF ablation in an asymptomatic patient requires additional discussion with the patient because the potential benefits of the procedure for the patient without symptoms are uncertain.
      IIbC-EO
      • Forleo G.B.
      • et al.
      Clinical impact of catheter ablation in patients with asymptomatic atrial fibrillation: the IRON-AF (Italian registry on NavX atrial fibrillation ablation procedures) study.
      • Wu L.
      • et al.
      Comparison of radiofrequency catheter ablation between asymptomatic and symptomatic persistent atrial fibrillation: a propensity score matched analysis.
      Persistent: Catheter ablation may be considered in select patients.IIbC-EO
      • Mohanty S.
      • et al.
      Catheter ablation of asymptomatic longstanding persistent atrial fibrillation: impact on quality of life, exercise performance, arrhythmia perception, and arrhythmia-free survival.
      Indications for surgical ablation of atrial fibrillation
      C. Indications for concomitant open (such as mitral valve) surgical ablation of atrial fibrillation
      Symptomatic AF refractory or intolerant to at least one Class I or III antiarrhythmic medicationParoxysmal: Surgical ablation is recommended.IB-NR
      U.S. Food and Drug Administration
      Summary of Safety and Effectiveness Data: AtriCure Synergy Ablation System, PMA P100046.
      • Badhwar V.
      • et al.
      The Society of Thoracic Surgeons Mitral Repair/Replacement Composite Score: a report of the Society of Thoracic Surgeons Quality Measurement Task Force.
      • Abreu Filho C.A.
      • et al.
      Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease.
      • Doukas G.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: a randomized controlled trial.
      • Blomstrom-Lundqvist C.
      • et al.
      A randomized double-blind study of epicardial left atrial cryoablation for permanent atrial fibrillation in patients undergoing mitral valve surgery: the SWEDish Multicentre Atrial Fibrillation study (SWEDMAF).
      • Chevalier P.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery: a prospective randomized multicentre study (SAFIR).
      • Cheng D.C.
      • et al.
      Surgical ablation for atrial fibrillation in cardiac surgery: a meta-analysis and systematic review.
      • Budera P.
      • et al.
      Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study.
      • Phan K.
      • et al.
      Surgical ablation for treatment of atrial fibrillation in cardiac surgery: a cumulative meta-analysis of randomised controlled trials.
      • Gillinov A.M.
      • et al.
      Surgical ablation of atrial fibrillation during mitral-valve surgery.
      • Rankin J.S.
      • et al.
      The Society of Thoracic Surgeons risk model for operative mortality after multiple valve surgery.
      • Louagie Y.
      • et al.
      Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone.
      • Chiappini B.
      • Di Bartolomeo R.
      • Marinelli G.
      Radiofrequency ablation for atrial fibrillation: different approaches.
      • Barnett S.D.
      • Ad N.
      Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis.
      Persistent: Surgical ablation is recommended.IB-NR
      U.S. Food and Drug Administration
      Summary of Safety and Effectiveness Data: AtriCure Synergy Ablation System, PMA P100046.
      • Badhwar V.
      • et al.
      The Society of Thoracic Surgeons Mitral Repair/Replacement Composite Score: a report of the Society of Thoracic Surgeons Quality Measurement Task Force.
      • Abreu Filho C.A.
      • et al.
      Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease.
      • Doukas G.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: a randomized controlled trial.
      • Blomstrom-Lundqvist C.
      • et al.
      A randomized double-blind study of epicardial left atrial cryoablation for permanent atrial fibrillation in patients undergoing mitral valve surgery: the SWEDish Multicentre Atrial Fibrillation study (SWEDMAF).
      • Chevalier P.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery: a prospective randomized multicentre study (SAFIR).
      • Cheng D.C.
      • et al.
      Surgical ablation for atrial fibrillation in cardiac surgery: a meta-analysis and systematic review.
      • Budera P.
      • et al.
      Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study.
      • Phan K.
      • et al.
      Surgical ablation for treatment of atrial fibrillation in cardiac surgery: a cumulative meta-analysis of randomised controlled trials.
      • Gillinov A.M.
      • et al.
      Surgical ablation of atrial fibrillation during mitral-valve surgery.
      • Rankin J.S.
      • et al.
      The Society of Thoracic Surgeons risk model for operative mortality after multiple valve surgery.
      • Louagie Y.
      • et al.
      Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone.
      • Chiappini B.
      • Di Bartolomeo R.
      • Marinelli G.
      Radiofrequency ablation for atrial fibrillation: different approaches.
      • Barnett S.D.
      • Ad N.
      Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis.
      Long-standing persistent: Surgical ablation is recommended.IB-NR
      U.S. Food and Drug Administration
      Summary of Safety and Effectiveness Data: AtriCure Synergy Ablation System, PMA P100046.
      • Badhwar V.
      • et al.
      The Society of Thoracic Surgeons Mitral Repair/Replacement Composite Score: a report of the Society of Thoracic Surgeons Quality Measurement Task Force.
      • Abreu Filho C.A.
      • et al.
      Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease.
      • Doukas G.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: a randomized controlled trial.
      • Blomstrom-Lundqvist C.
      • et al.
      A randomized double-blind study of epicardial left atrial cryoablation for permanent atrial fibrillation in patients undergoing mitral valve surgery: the SWEDish Multicentre Atrial Fibrillation study (SWEDMAF).
      • Chevalier P.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery: a prospective randomized multicentre study (SAFIR).
      • Cheng D.C.
      • et al.
      Surgical ablation for atrial fibrillation in cardiac surgery: a meta-analysis and systematic review.
      • Budera P.
      • et al.
      Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study.
      • Phan K.
      • et al.
      Surgical ablation for treatment of atrial fibrillation in cardiac surgery: a cumulative meta-analysis of randomised controlled trials.
      • Gillinov A.M.
      • et al.
      Surgical ablation of atrial fibrillation during mitral-valve surgery.
      • Rankin J.S.
      • et al.
      The Society of Thoracic Surgeons risk model for operative mortality after multiple valve surgery.
      • Louagie Y.
      • et al.
      Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone.
      • Chiappini B.
      • Di Bartolomeo R.
      • Marinelli G.
      Radiofrequency ablation for atrial fibrillation: different approaches.
      • Barnett S.D.
      • Ad N.
      Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis.
      Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class I or III antiarrhythmic medicationParoxysmal: Surgical ablation is recommended.IB-NR
      U.S. Food and Drug Administration
      Summary of Safety and Effectiveness Data: AtriCure Synergy Ablation System, PMA P100046.
      • Badhwar V.
      • et al.
      The Society of Thoracic Surgeons Mitral Repair/Replacement Composite Score: a report of the Society of Thoracic Surgeons Quality Measurement Task Force.
      • Abreu Filho C.A.
      • et al.
      Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease.
      • Doukas G.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: a randomized controlled trial.
      • Blomstrom-Lundqvist C.
      • et al.
      A randomized double-blind study of epicardial left atrial cryoablation for permanent atrial fibrillation in patients undergoing mitral valve surgery: the SWEDish Multicentre Atrial Fibrillation study (SWEDMAF).
      • Chevalier P.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery: a prospective randomized multicentre study (SAFIR).
      • Cheng D.C.
      • et al.
      Surgical ablation for atrial fibrillation in cardiac surgery: a meta-analysis and systematic review.
      • Budera P.
      • et al.
      Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study.
      • Phan K.
      • et al.
      Surgical ablation for treatment of atrial fibrillation in cardiac surgery: a cumulative meta-analysis of randomised controlled trials.
      • Gillinov A.M.
      • et al.
      Surgical ablation of atrial fibrillation during mitral-valve surgery.
      • Rankin J.S.
      • et al.
      The Society of Thoracic Surgeons risk model for operative mortality after multiple valve surgery.
      • Louagie Y.
      • et al.
      Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone.
      • Chiappini B.
      • Di Bartolomeo R.
      • Marinelli G.
      Radiofrequency ablation for atrial fibrillation: different approaches.
      • Barnett S.D.
      • Ad N.
      Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis.
      Persistent: Surgical ablation is recommended.IB-NR
      U.S. Food and Drug Administration
      Summary of Safety and Effectiveness Data: AtriCure Synergy Ablation System, PMA P100046.
      • Badhwar V.
      • et al.
      The Society of Thoracic Surgeons Mitral Repair/Replacement Composite Score: a report of the Society of Thoracic Surgeons Quality Measurement Task Force.
      • Abreu Filho C.A.
      • et al.
      Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease.
      • Doukas G.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: a randomized controlled trial.
      • Blomstrom-Lundqvist C.
      • et al.
      A randomized double-blind study of epicardial left atrial cryoablation for permanent atrial fibrillation in patients undergoing mitral valve surgery: the SWEDish Multicentre Atrial Fibrillation study (SWEDMAF).
      • Chevalier P.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery: a prospective randomized multicentre study (SAFIR).
      • Cheng D.C.
      • et al.
      Surgical ablation for atrial fibrillation in cardiac surgery: a meta-analysis and systematic review.
      • Budera P.
      • et al.
      Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study.
      • Phan K.
      • et al.
      Surgical ablation for treatment of atrial fibrillation in cardiac surgery: a cumulative meta-analysis of randomised controlled trials.
      • Gillinov A.M.
      • et al.
      Surgical ablation of atrial fibrillation during mitral-valve surgery.
      • Rankin J.S.
      • et al.
      The Society of Thoracic Surgeons risk model for operative mortality after multiple valve surgery.
      • Louagie Y.
      • et al.
      Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone.
      • Chiappini B.
      • Di Bartolomeo R.
      • Marinelli G.
      Radiofrequency ablation for atrial fibrillation: different approaches.
      • Barnett S.D.
      • Ad N.
      Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis.
      Long-standing persistent: Surgical ablation is recommended.IB-NR
      U.S. Food and Drug Administration
      Summary of Safety and Effectiveness Data: AtriCure Synergy Ablation System, PMA P100046.
      • Badhwar V.
      • et al.
      The Society of Thoracic Surgeons Mitral Repair/Replacement Composite Score: a report of the Society of Thoracic Surgeons Quality Measurement Task Force.
      • Abreu Filho C.A.
      • et al.
      Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease.
      • Doukas G.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: a randomized controlled trial.
      • Blomstrom-Lundqvist C.
      • et al.
      A randomized double-blind study of epicardial left atrial cryoablation for permanent atrial fibrillation in patients undergoing mitral valve surgery: the SWEDish Multicentre Atrial Fibrillation study (SWEDMAF).
      • Chevalier P.
      • et al.
      Left atrial radiofrequency ablation during mitral valve surgery: a prospective randomized multicentre study (SAFIR).
      • Cheng D.C.
      • et al.
      Surgical ablation for atrial fibrillation in cardiac surgery: a meta-analysis and systematic review.
      • Budera P.
      • et al.
      Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study.
      • Phan K.
      • et al.
      Surgical ablation for treatment of atrial fibrillation in cardiac surgery: a cumulative meta-analysis of randomised controlled trials.
      • Gillinov A.M.
      • et al.
      Surgical ablation of atrial fibrillation during mitral-valve surgery.
      • Rankin J.S.
      • et al.
      The Society of Thoracic Surgeons risk model for operative mortality after multiple valve surgery.
      • Louagie Y.
      • et al.
      Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone.
      • Chiappini B.
      • Di Bartolomeo R.
      • Marinelli G.
      Radiofrequency ablation for atrial fibrillation: different approaches.
      • Barnett S.D.
      • Ad N.
      Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis.
      D. Indications for concomitant closed (such as CABG and AVR) surgical ablation of atrial fibrillation
      Symptomatic AF refractory or intolerant to at least one Class I or III antiarrhythmic medicationParoxysmal: Surgical ablation is recommended.IB-NR
      • Edgerton J.R.
      • Jackman W.M.
      • Mack M.J.
      A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set.
      • Edgerton J.R.
      • et al.
      Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the “Dallas” lesion set.
      • Lockwood D.
      • et al.
      Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions.
      • Malaisrie S.C.
      • et al.
      Atrial fibrillation ablation in patients undergoing aortic valve replacement.
      • Cherniavsky A.
      • et al.
      Assessment of results of surgical treatment for persistent atrial fibrillation during coronary artery bypass grafting using implantable loop recorders.
      • Yoo J.S.
      • et al.
      Impact of concomitant surgical atrial fibrillation ablation in patients undergoing aortic valve replacement.
      Persistent: Surgical ablation is recommended.IB-NR
      • Edgerton J.R.
      • Jackman W.M.
      • Mack M.J.
      A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set.
      • Edgerton J.R.
      • et al.
      Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the “Dallas” lesion set.
      • Lockwood D.
      • et al.
      Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions.
      • Malaisrie S.C.
      • et al.
      Atrial fibrillation ablation in patients undergoing aortic valve replacement.
      • Cherniavsky A.
      • et al.
      Assessment of results of surgical treatment for persistent atrial fibrillation during coronary artery bypass grafting using implantable loop recorders.
      • Yoo J.S.
      • et al.
      Impact of concomitant surgical atrial fibrillation ablation in patients undergoing aortic valve replacement.
      Long-standing persistent: Surgical ablation is recommended.IB-NR
      • Edgerton J.R.
      • Jackman W.M.
      • Mack M.J.
      A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set.
      • Edgerton J.R.
      • et al.
      Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the “Dallas” lesion set.
      • Lockwood D.
      • et al.
      Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions.
      • Malaisrie S.C.
      • et al.
      Atrial fibrillation ablation in patients undergoing aortic valve replacement.
      • Cherniavsky A.
      • et al.
      Assessment of results of surgical treatment for persistent atrial fibrillation during coronary artery bypass grafting using implantable loop recorders.
      • Yoo J.S.
      • et al.
      Impact of concomitant surgical atrial fibrillation ablation in patients undergoing aortic valve replacement.
      Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class I or III antiarrhythmic medicationParoxysmal: Surgical ablation is reasonable.IIaB-NR
      • Edgerton J.R.
      • Jackman W.M.
      • Mack M.J.
      A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set.
      • Edgerton J.R.
      • et al.
      Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the “Dallas” lesion set.
      • Lockwood D.
      • et al.
      Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions.
      • Malaisrie S.C.
      • et al.
      Atrial fibrillation ablation in patients undergoing aortic valve replacement.
      • Cherniavsky A.
      • et al.
      Assessment of results of surgical treatment for persistent atrial fibrillation during coronary artery bypass grafting using implantable loop recorders.
      • Yoo J.S.
      • et al.
      Impact of concomitant surgical atrial fibrillation ablation in patients undergoing aortic valve replacement.
      Persistent: Surgical ablation is reasonable.IIaB-NR
      • Edgerton J.R.
      • Jackman W.M.
      • Mack M.J.
      A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set.
      • Edgerton J.R.
      • et al.
      Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the “Dallas” lesion set.
      • Lockwood D.
      • et al.
      Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions.
      • Malaisrie S.C.
      • et al.
      Atrial fibrillation ablation in patients undergoing aortic valve replacement.
      • Cherniavsky A.
      • et al.
      Assessment of results of surgical treatment for persistent atrial fibrillation during coronary artery bypass grafting using implantable loop recorders.
      • Yoo J.S.
      • et al.
      Impact of concomitant surgical atrial fibrillation ablation in patients undergoing aortic valve replacement.
      Long-standing persistent: Surgical ablation is reasonable.IIaB-NR
      • Edgerton J.R.
      • Jackman W.M.
      • Mack M.J.
      A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set.
      • Edgerton J.R.
      • et al.
      Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the “Dallas” lesion set.
      • Lockwood D.
      • et al.
      Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions.
      • Malaisrie S.C.
      • et al.
      Atrial fibrillation ablation in patients undergoing aortic valve replacement.
      • Cherniavsky A.
      • et al.
      Assessment of results of surgical treatment for persistent atrial fibrillation during coronary artery bypass grafting using implantable loop recorders.
      • Yoo J.S.
      • et al.
      Impact of concomitant surgical atrial fibrillation ablation in patients undergoing aortic valve replacement.
      E. Indications for stand-alone and hybrid surgical ablation of atrial fibrillation
      Symptomatic AF refractory or intolerant to at least one Class I or III antiarrhythmic medicationParoxysmal: Stand-alone surgical ablation can be considered for patients who have failed one or more attempts at catheter ablation and also for those who are intolerant or refractory to antiarrhythmic drug therapy and prefer a surgical approach, after review of the relative safety and efficacy of catheter ablation versus a stand-alone surgical approach.IIbB-NR
      • Edgerton J.R.
      • Jackman W.M.
      • Mack M.J.
      A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set.
      • Edgerton J.R.
      • et al.
      Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the “Dallas” lesion set.
      • Lockwood D.
      • et al.
      Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions.
      • Driessen A.H.
      • et al.
      Ganglion Plexus Ablation in Advanced Atrial Fibrillation: The AFACT Study.
      • Boersma L.V.
      • et al.
      Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial.
      • Henn M.C.
      • et al.
      Late outcomes after the Cox maze IV procedure for atrial fibrillation.
      • Krul S.P.
      • et al.
      Navigating the mini-maze: systematic review of the first results and progress of minimally-invasive surgery in the treatment of atrial fibrillation.
      • Cox J.L.
      • et al.
      The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure.
      • Rodriguez E.
      • et al.
      Minimally invasive bi-atrial CryoMaze operation for atrial fibrillation.
      • Wolf R.K.
      • et al.
      Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation.
      • Edgerton J.R.
      • et al.
      Minimally invasive pulmonary vein isolation and partial autonomic denervation for surgical treatment of atrial fibrillation.
      • Edgerton J.R.
      • et al.
      Minimally invasive surgical ablation of atrial fibrillation: six-month results.
      • Beyer E.
      • Lee R.
      • Lam B.K.
      Point: Minimally invasive bipolar radiofrequency ablation of lone atrial fibrillation: early multicenter results.
      • Kearney K.
      • et al.
      A systematic review of surgical ablation versus catheter ablation for atrial fibrillation.
      • Ad N.
      • et al.
      Surgical ablation of atrial fibrillation trends and outcomes in North America.
      • Driessen A.H.
      • et al.
      Electrophysiologically guided thoracoscopic surgery for advanced atrial fibrillation: 5-year follow-up.
      • Khargi K.
      • et al.
      Surgical treatment of atrial fibrillation; a systematic review.
      • Wazni O.M.
      • et al.
      Atrial arrhythmias after surgical maze: findings during catheter ablation.
      Persistent: Stand-alone surgical ablation is reasonable for patients who have failed one or more attempts at catheter ablation and also for those patients who prefer a surgical approach after review of the relative safety and efficacy of catheter ablation versus a stand-alone surgical approach.IIaB-NR
      • Edgerton J.R.
      • Jackman W.M.
      • Mack M.J.
      A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set.
      • Edgerton J.R.
      • et al.
      Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the “Dallas” lesion set.
      • Lockwood D.
      • et al.
      Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions.
      • Driessen A.H.
      • et al.
      Ganglion Plexus Ablation in Advanced Atrial Fibrillation: The AFACT Study.
      • Boersma L.V.
      • et al.
      Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial.
      • Henn M.C.
      • et al.
      Late outcomes after the Cox maze IV procedure for atrial fibrillation.
      • Krul S.P.
      • et al.
      Navigating the mini-maze: systematic review of the first results and progress of minimally-invasive surgery in the treatment of atrial fibrillation.
      • Cox J.L.
      • et al.
      The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure.
      • Rodriguez E.
      • et al.
      Minimally invasive bi-atrial CryoMaze operation for atrial fibrillation.
      • Wolf R.K.
      • et al.
      Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation.
      • Edgerton J.R.
      • et al.
      Minimally invasive pulmonary vein isolation and partial autonomic denervation for surgical treatment of atrial fibrillation.
      • Edgerton J.R.
      • et al.
      Minimally invasive surgical ablation of atrial fibrillation: six-month results.
      • Beyer E.
      • Lee R.
      • Lam B.K.
      Point: Minimally invasive bipolar radiofrequency ablation of lone atrial fibrillation: early multicenter results.
      • Kearney K.
      • et al.
      A systematic review of surgical ablation versus catheter ablation for atrial fibrillation.
      • Ad N.
      • et al.
      Surgical ablation of atrial fibrillation trends and outcomes in North America.
      • Driessen A.H.
      • et al.
      Electrophysiologically guided thoracoscopic surgery for advanced atrial fibrillation: 5-year follow-up.
      • Khargi K.
      • et al.
      Surgical treatment of atrial fibrillation; a systematic review.
      • Wazni O.M.
      • et al.
      Atrial arrhythmias after surgical maze: findings during catheter ablation.
      Long-standing persistent: Stand-alone surgical ablation is reasonable for patients who have failed one or more attempts at catheter ablation and also for those patients who prefer a surgical approach after review of the relative safety and efficacy of catheter ablation versus a stand-alone surgical approach.IIaB-NR
      • Edgerton J.R.
      • Jackman W.M.
      • Mack M.J.
      A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set.
      • Edgerton J.R.
      • et al.
      Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the “Dallas” lesion set.
      • Lockwood D.
      • et al.
      Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions.
      • Driessen A.H.
      • et al.
      Ganglion Plexus Ablation in Advanced Atrial Fibrillation: The AFACT Study.
      • Boersma L.V.
      • et al.
      Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial.