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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e86

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

per quality adjusted life-year added, values within the intermediate value range (between $50 000 and $150 000 per quality29,30,52–55 adjusted life-year added) by ACC/AHA criteria. Models of the costeffectiveness of catheter ablation have reported more favorable results, but their results generally depended on assumptions that ablation reduced mortality, or ischemic stroke, or both, which have not been proven. 7.	 In most patients, continued untreated AF will lead

to progression and higher AF burden associated with worse clinical outcomes.31–39 In patients with subclinical AF <24 hours, progression to overt AF or episodes >24 hours occurs at a rate of 8.8% per year, and those patients who develop AF are more likely to be hospitalized for HF.56 Several observational studies have reported AF progression may be improved by using a catheter-based ablation rhythm-control strategy.33–35,37,38 As an example, in 1 randomized trial that was stopped prematurely, in 255 patients with paroxysmal AF randomized to catheter ablation or antiarrhythmic medication, freedom from persistent AF or AT was significantly higher with catheter ablation (ablation: 2.4%, versus antiarrhythmic medication, 17.5%, 1-sided P=0.0009).57 However, serious adverse events associated with the ablation were observed in 8% of patients.57 Despite the potential risks associated with catheter ablation, in a recent analysis of a large registry that specifically evaluated asymptomatic patients, rhythm control was associated with an improvement in the composite outcome of cardiac death, ischemic stroke, and hospitalization for HF.58 The impact was largest in those patients who underwent catheter ablation for rhythm control, particularly in those with paroxysmal AF, LA diameters ≤50 mm,58 or higher stroke risk (CHA2DS2-VASc score ≥3). In a post hoc analysis of EAST-AFNET 4, the magnitude of benefit from a rhythm-control strategy for reducing the primary composite outcome of cardiovascular death, stroke, or hospitalizations for HF or ACS was independent of symptom status, and catheter ablation for rhythm control was used in approximately 20% of patients, whether symptomatic or not.59

8.4.1. Patient Selection Patient selection is the first step and a critically important step in deciding candidacy for catheter ablation.1–4 Younger patients are likely to derive greater long-term benefit, including delaying AF progression. However, clinical trials have demonstrated improved cardiovascular outcomes with rhythm control, even with median ages in the 70s.5 Patients with minimal atrial enlargement have the best outcomes,6 whereas increased myocardial fibrosis7,8 and more persistent forms of AF are associated with higher rates of recurrence after ablation. Time from diagnosis to ablation is also associated with improved outcomes after ablation.9,10 Although the likelihood of recurrence of AF is 1 factor that should be considered, it is difficult to predict,11 and certain patients may derive even greater benefits from catheter ablation, such as in patients with HFrEF, who have been shown to have improved functional status, LV function, and cardiovascular outcomes.12–14

In some patients, ablation should be avoided as it is unlikely to be successful due to overwhelming substrate or ongoing physiologic processes that either strongly perpetuate the risk of AF or make maintenance of sinus rhythm unlikely. These situations include but are not limited to advanced infiltrative cardiomyopathies like amyloid, severe mitral stenosis or regurgitation, and cor pulmonale.

8.4.2 Techniques and Technologies for AF Catheter Ablation

Recommendations for Techniques and Technologies for AF Catheter Ablation Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 A 1 In patients undergoing ablation for AF, PVI is recom-

mended as the primary lesion set for all patients unless a different specific trigger is identified.1–7

2b B-R 2 In patients undergoing ablation for AF, the value of

other endpoints beyond PVI such as noninducibility and ablation of additional anatomic ablation targets (eg, posterior wall sites, low voltage areas, complex fractionated electrograms, rotors) is uncertain.8–18

Synopsis Catheter ablation is now established as an effective option for rhythm control in patients with AF and AFL.1–7,16 However, in patients with AF, additional ablation targets beyond isolation of PVI as a routine strategy have not reduced AF recurrence or burden in RCTs.8–18 Although achieving durable pulmonary vein ablation in patients with AF has been associated with less recurrent arrhythmias, other endpoints, such as termination of F and noninducibility, have not been associated with improved outcomes.19–28 Significant complications of AF ablation include stroke and TIAs, pericardial effusion, and vascular complications.16 The most serious complication that occurs after the ablation procedure is development of an esophageal atrial fistula, although other complications, such as PV stenosis can occur.8–18 Recommendation-Specific Supportive Text 1.	 Multiple randomized studies have shown that PVI

is more effective than medical therapy for reducing AF burden.1–7 A recent meta-analysis of 6 RCTs found that strategies that included PVI were associated with a 50% reduction in the development of recurrent AF when compared with strategies that did not include PVI.7

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