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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e85

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

group were free from recurrent arrhythmia compared with 16% in the antiarrhythmic drug group.8 Finally, most recently, in the CABANA trial, 80% of patients were on an antiarrhythmic medication and thought to be candidates for AF ablation and were randomized to catheter ablation or continued antiarrhythmic therapy. Catheter ablation was associated with a nearly 50% reduction in recurrent AF (HR, 0.52 [95% CI, 0.45-0.60]; P<0.001).4,28

2 In selected patients with paroxysmal AF, ablation is

a suitable first-line option. Several initial RCTs suggested a decrease in recurrent AF or AF burden with catheter ablation when compared with antiarrhythmic drugs.16 More recent trials have shown a significant reduction in recurrent AF with catheter ablation compared with antiarrhythmic drugs. In a follow-up report of 1 study, after 3-year follow-up, catheter ablation continued to be associated with a significant decrease in recurrent atrial tachyarrhythmias when compared with antiarrhythmic drugs (HR, 0.51 [95% CI, 0.38-0.67]).14 More importantly, episodes of persistent AF developed in only 1.9% of patients randomized to catheter ablation compared with 7.4% of patients in the antiarrhythmic drug arm (HR, 0.25 [95% CI, 0.13-0.70]).14 All of the studies that have evaluated catheter ablation as an initial strategy for rhythm control in patients with paroxysmal AF, although fairly standard exclusion criteria were used, enrolled relatively young patients (average age approximately 60 years) who had relatively few comorbidities (if present, mainly hypertension).16

3 AFL is most commonly due to the critical isthmus

formed by the inferior vena cava and the tricuspid valve. More rarely, in patients who have not undergone previous ablation procedures atypical AFL or focal ATs can be observed. Catheter ablation of typical AFL is effective and relatively low risk.17–19 In an older meta-analysis of AFL ablation studies, AFL ablation was associated with an acute success rate of 90% and a complication rate of 2.6%.18 The occurrence of AF after AFL ablation was 34%, with a recurrence rate of 23% in those patients without a history of AF compared with 53% in patients with a history of AF. By 5 years, AF developed in 60% to 70% of patients regardless of whether the patient had a history of AF before the AFL ablation. Little evidence is available in these studies for the clinical significance of AF after AFL ablation. 4.	 AF can be associated with other atrial arrhyth-

mias, particularly AFL.20–22 During ablation for AF, ablation of previously documented or inducible sustained SVT or AFL is useful to reduce the likelihood of recurrent arrhythmias.22–25 Although ablation alone for AF in patients with both AF and AFL will reduce the likelihood of AFL, and ablation targeting an inducible SVT in a patient with AF may reduce future AF, in both cases the likelihood of recurrent arrhythmias is high, although the actual recurrence rate will depend on the specific population.17,18,25–27,48,49 Conversely, prophylactic catheter ablation of the CTI in patients without documented or inducible AFL likely has minimal benefit.50 Alternatively, in 1 study, cryoballoon PVI as first-line treatment for AFL is equally effective compared with standard CTI ablation for preventing recurrence of atrial arrhythmia and better at preventing new-onset AF.51

5 Several randomized trials have compared catheter

ablation to AADs as first-line therapy for AF.11–13 In the MANTRA-AF study, ablation and antiarrhythmic drugs as first-line therapy for paroxysmal AF was evaluated. Although no differences in AF were identified during the first 18 months, at 24-month follow-up, ablation was associated with a lower AF burden (ablation, 9% versus antiarrhythmic drugs, 18%; P=0.004).11 Subsequent studies have demonstrated similar results: In the EARLY-AF (Early Aggressive Invasive Intervention for Atrial Fibrillation) study, at 1-year follow-up, recurrent atrial arrhythmias were identified in 43% of the ablation group and 68% of the antiarrhythmic drug group (P<0.001), and in the STOP AF First (Cryoballoon Catheter Ablation in an Antiarrhythmic Drug Naive Paroxysmal Atrial Fibrillation) study, recurrent atrial arrhythmias were identified in 25% of the ablation group and 55% of the antiarrhythmic drug group (P<0.001).12,13 Procedural complications were observed in 2% to 5% of patients in all 3 studies.11–13 Although AF burden was significantly reduced with ablation compared with antiarrhythmic drug therapy in EARLY-AF, AF burden was low with either strategy (percentage of time in AF: ablation, 0.6% versus antiarrhythmic drugs, 3.9%) and, in all 3 trials, the average age was ≤60 years.11–13 Although these trials enrolled patients with paroxysmal AF, recent studies have consistently found that catheter ablation is more commonly used and also effective in patients with persistent AF, particularly if of relatively recent onset (<1 year).28

6 Catheter ablation for AF is a costly procedure yet

appears to provide value by improving the symptoms of AF and patient QOL. Some of the initially higher costs of the ablation procedure may be offset by reductions in subsequent cardiovascular hospitalizations. Formal economic analyses have been performed alongside 2 randomized controlled clinical trials. Both trials showed higher costs and improved QOL during follow-up, with incremental cost-effectiveness ratios of $58 000 and €51 000

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