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

Chair: Hugh Calkins, MD, Johns Hopkins Medical Institutions, Baltimore, MD, USA.

Section Chairs: Definitions, Mechanisms, and Rationale for AF Ablation: Shih-Ann Chen, MD, National Yang-Ming University, Taipei, Taiwan.

Modifiable Risk Factors for AF and Impact on Ablation: Jonathan M. Kalman, MBBS, PhD, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia.

Indications: Claudio Tondo, MD, PhD, Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy.

Strategies, Techniques, and Endpoints: Karl Heinz Kuck, MD, PhD, Asklepios Klinik St. Georg, Hamburg, Germany.

Technology and Tools: Andrea Natale, MD, Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA.

Technical Aspects of Ablation to Maximize Safety and Anticoagulation: David E. Haines, MD, Beaumont Health System, Royal Oak, MI, USA.

Follow-up Considerations: Francis E. Marchlinski, MD, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.

Outcomes and Efficacy: Matthew R. Reynolds, MD, MSc, Lahey Hospital and Medical Center, Burlington, MA, USA.

Complications: D. Wyn Davies, MD, Imperial College Healthcare NHS Trust, London, United Kingdom.

Training Requirements: Bruce D. Lindsay, MD, Cleveland Clinic, Cleveland, OH, USA.

Surgical and Hybrid AF Ablation: James R. Edgerton, MD, The Heart Hospital, Baylor Plano, Plano, TX, USA.

Clinical Trial Design: Atul Verma, MD, Southlake Regional Health Centre, University of Toronto, Toronto, Canada.

Correspondence: Heart Rhythm Society, 1325 G Street NW, Suite 400, Washington, DC 20005. E-mail address: clinicaldocs@hrsonline.org.

Document Reviewers: Carina Blomström-Lundqvist, MD, PhD; Angelo A.V. De Paola, MD, PhD; Peter M. Kistler, MBBS, PhD; Gregory Y.H. Lip, MD; Nicholas S. Peters, MD; Cristiano F. Pisani, MD; Antonio Raviele, MD; Eduardo B. Saad, MD, PhD; Kazuhiro Satomi, MD, PhD; Martin K. Stiles, MB ChB, PhD; Stephan Willems, MD, PhD

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) [1]. 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 [2]. 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 Table 14 and Appendix B Table 15.

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 [3, 4]. 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 [5, 6]. 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.

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, Figs. 1, 2, 3, 4, 5, and 6).

Table 1 Atrial fibrillation definitions
Fig. 1
figure1

Anatomical 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

Fig. 2
figure2

This 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

Fig. 3
figure3

Schematic 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

Fig. 4
figure4

Structure 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 [2]

Fig. 5
figure5

Schematic 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

Fig. 6
figure6

Schematic 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 [2]

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.

Indications

Shown in Table 2, and summarized in Figs. 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 2 Indications for catheter (A and B) and surgical (C, D, and E) ablation of atrial fibrillation
Fig. 7
figure7

Indications for catheter ablation of symptomatic atrial fibrillation. Shown in this figure are the indications for catheter ablation of symptomatic paroxysmal, persistent, and long-standing persistent AF. The Class for each indication based on whether ablation is performed after failure of antiarrhythmic drug therapy or as first-line therapy is shown. Please refer to Table 2B and the text for the indications for catheter ablation of asymptomatic AF

Fig. 8
figure8

Indications for surgical ablation of atrial fibrillation. Shown in this figure are the indications for surgical ablation of paroxysmal, persistent, and long-standing persistent AF. The Class for each indication based on whether ablation is performed after failure of antiarrhythmic drug therapy or as first-line therapy is shown. The indications for surgical AF ablation are divided into whether the AF ablation procedure is performed concomitantly with an open surgical procedure (such as mitral valve replacement), a closed surgical procedure (such as coronary artery bypass graft surgery), or as a stand-alone surgical AF ablation procedure performed solely for treatment of atrial fibrillation

Strategies, techniques, and endpoints

The writing group recommendations for techniques to be used for ablation of persistent and long-standing persistent AF (Table 3), adjunctive ablation strategies, nonablative strategies to improve outcomes of AF ablation, and endpoints for ablation of paroxysmal, persistent, and long-standing persistent AF are covered in this section. A schematic overview of common lesion sets created during an AF ablation procedure is shown in Fig. 6.

Table 3 Atrial fibrillation ablation: strategies, techniques, and endpoints

Technology and tools

This section of the consensus statement provides an update on many of the technologies and tools that are employed for AF ablation procedures. It is important to recognize that this is not a comprehensive listing and that new technologies, tools, and approaches are being developed. It is also important to recognize that radiofrequency (RF) energy is the dominant energy source available for ablation of typical and atypical atrial flutter (AFL). Although cryoablation is a commonly employed tool for AF ablation, it is not well suited for ablation of typical or atypical AFL. Other energy sources and tools are available in some parts of the world and/or are in various stages of development and/or clinical investigation. Shown in Fig. 9 are schematic drawings of AF ablation using point-by-point RF energy (Fig. 9a) and AF ablation using the cryoballoon (CB) system (Fig. 9b).

Fig. 9
figure9

Schematic drawing showing catheter ablation of atrial fibrillation using either RF energy or cryoballoon AF ablation. a Shows a typical wide area lesion set created using RF energy. Ablation lesions are delivered in a figure of eight pattern around the left and right PV veins. Also shown is a linear cavotricuspid isthmus lesion created for ablation of typical atrial flutter in a patient with a prior history of typical atrial flutter or inducible isthmus-dependent typical atrial flutter at the time of ablation. A multielectrode circular mapping catheter is positioned in the left inferior PV. b Shows an ablation procedure using the cryoballoon system. Ablation lesions have been created surrounding the right PVs, and the cryoballoon ablation catheter is positioned in the left superior PV. A through the lumen multielectrode circular mapping catheter is positioned in the left superior PV. Illustration: Tim Phelps © 2017 Johns Hopkins University, AAM

Technical aspects of ablation to maximize safety and anticoagulation

Anticoagulation strategies pre-, during, and postcatheter ablation of AF (Table 4); signs and symptoms of complications that can occur within the first several months following ablation (Table 5); anesthesia or sedation during ablation; and approaches to minimize risk of an atrial esophageal fistula are discussed in this section.

Table 4 Anticoagulation strategies: pre-, during, and postcatheter ablation of AF
Table 5 Signs and symptoms following AF ablation

Follow-up considerations

AF ablation is an invasive procedure that entails risks, most of which are present during the acute procedural period. However, complications can also occur in the weeks or months following ablation. Recognizing common symptoms after AF ablation and distinguishing those that require urgent evaluation and referral to an electrophysiologist is an important part of follow-up after AF ablation. The success of AF ablation is based in large part on freedom from AF recurrence based on ECG monitoring. Arrhythmia monitoring can be performed with the use of noncontinuous or continuous ECG monitoring tools (Table 6). This section also discusses the important topics of AAD and non-AAD use prior to and following AF ablation, the role of cardioversion, as well as the indications for and timing of repeat AF ablation procedures.

Table 6 Types of ambulatory cardiac monitoring devices

Outcomes and efficacy

This section provides a comprehensive review of the outcomes of catheter ablation of AF. Table 7 summarizes the main findings of the most important clinical trials in this field. Outcomes of AF ablation in subsets of patients not well represented in these trials are reviewed. Outcomes for specific ablation systems and strategies (CB ablation, rotational activity ablation, and laser balloon ablation) are also reviewed.

Table 7 Selected clinical trials of catheter ablation of atrial fibrillation and/or for FDA approval

Complications

Catheter ablation of AF is one of the most complex interventional electrophysiological procedures. AF ablation by its nature involves catheter manipulation and ablation in the delicate thin-walled atria, which are in close proximity to other important organs and structures that can be impacted through collateral damage. It is therefore not surprising that AF ablation is associated with a significant risk of complications, some of which might result in life-long disability and/or death. This section reviews the complications associated with catheter ablation procedures performed to treat AF. The types and incidence of complications are presented, their mechanisms are explored, and the optimal approach to prevention and treatment is discussed (Tables 8 and 9).

Table 8 Definitions of complications associated with AF ablation
Table 9 Incidence, prevention, diagnosis, and treatment of selected complications of AF ablation

Training requirements

This section of the document outlines the training requirements for those who wish to perform catheter ablation of AF.

Surgical and hybrid AF ablation

Please refer to Table 2 and Fig. 8 presented earlier in this Executive Summary.

Clinical trial design

Although there have been many advances made in the field of catheter and surgical ablation of AF, there is still much to be learned about the mechanisms of initiation and maintenance of AF and how to apply this knowledge to the still-evolving techniques of AF ablation. Although single-center, observational reports have dominated the early days of this field, we are quickly moving into an era in which hypotheses are put through the rigor of testing in well-designed, randomized, multicenter clinical trials. It is as a result of these trials that conventional thinking about the best techniques, success rates, complication rates, and long-term outcomes beyond AF recurrence—such as thromboembolism and mortality—is being put to the test. The ablation literature has also seen a proliferation of meta-analyses and other aggregate analyses, which reinforce the need for consistency in the approach to reporting the results of clinical trials. This section reviews the minimum requirements for reporting on AF ablation trials. It also acknowledges the potential limitations of using specific primary outcomes and emphasizes the need for broad and consistent reporting of secondary outcomes to assist the end-user in determining not only the scientific, but also the clinical relevance of the results (Tables 10, 11, 12, and 13).

Table 10 Definitions for use when reporting outcomes of AF ablation and in designing clinical trials of catheter or surgical ablation of AF
Table 11 Quality-of-life scales, definitions, and strengths
Table 12 Non-AF recurrence–related endpoints for reporting in AF ablation trials
Table 13 Advantages and disadvantages of AF-related endpoints in AF ablation trials

Unanswered questions in AF ablation

There is still much to be learned about the mechanisms of AF, techniques of AF ablation, and long-term outcomes. The following are unanswered questions for future investigation:

  1. 1

    AF ablation and modification of stroke risk and need for ongoing oral anticoagulation (OAC): The CHA2DS2-VASc score was developed for patients with clinical AF. If a patient has received a successful ablation such that he/she no longer has clinical AF (subclinical, or no AF), then what is the need for ongoing OAC? Are there any patients in whom successful ablation could lead to discontinuation of OAC?

  2. 2

    Substrate modification in catheter-based management of AF—particularly for persistent AF: What is the proper lesion set required beyond pulmonary vein isolation? Do lines and complex fractionated atrial electrogram (CFAE) have any remaining role? Are these approaches ill-advised or simply discouraged?

    What is the role of targeting localized rotational activations? How do we ablate a localized rotational activation? How can scar be characterized and targeted for ablation? Do we need to replicate the MAZE procedure? Does the right atrium need to be targeted as well as the left atrium?

  3. 3

    Autonomic influence in AF: Is clinical AF really an autonomic mediated arrhythmia? Is elimination of ganglionated plexi required? Is there a role for autonomic modulation, for example, spinal cord or vagal stimulation?

  4. 4

    Contribution and modulation of risk factors on outcomes of AF ablation: Obesity reduction has been shown to reduce AF burden and recurrence in patients undergoing ablation. What is the role of bariatric surgery? Does the modulation of other risk factors influence outcome such as hypertension, sleep apnea, and diabetes?

  5. 5

    Outcomes in ablation of high-risk populations: Do high-risk populations benefit from AF ablation? Congestive heart failure has been assessed in smaller trials, but larger trials are required. Outcome data are needed in patients with very enlarged LAs, hypertrophic cardiomyopathy, patients with renal failure on dialysis, and the very elderly.

  6. 6

    Surgical vs catheter-based vs hybrid ablation: There should be more comparative work between percutaneous and minimally invasive surgical approaches. Both report similar outcomes, but there is a dearth of comparative data. Is there any patient benefit to hybrid procedures?

  7. 7

    How do we characterize patients who are optimal candidates for ablation? Preablation late gadolinium-enhanced (LGE)-magnetic resonance imaging (MRI) might identify patients with heavy burdens of scar who are unlikely to respond to ablation. These techniques must become reproducible and reliable and must be assessed in multicenter trials. Other markers need to be investigated, including genetic markers, biochemical markers, and clinical markers based on aggregated risk scores.

  8. 8

    The incremental role of new technologies: As newer and often more expensive technologies are produced for AF ablation, their definitive incremental value must be determined in order to justify change in practice or case cost. These technologies include global (basket) mapping techniques, newer ablation indices for assessing lesion durability, advanced imaging for viewing lesions in the myocardium, etc. New energy sources, including laser, low-intensity ultrasound, photonic particle therapy, external beam ablation, and MRI-guided ablation, must be assessed in comparative fashion.

  9. 9

    Outcomes of AF ablation: We need to better understand the clinical relevance of ablation outcomes. What is the significance of time to recurrence of 30 s of arrhythmia? How do we best quantify AF burden? How do these outcomes relate to quality of life and stroke risk?

  10. 10

    What is the role of surgical LA reduction? Does left atrial appendage (LAA) occlusion or obliteration improve outcome of persistent AF ablation with an accompanying reduction in stroke? Does ablation work through atrial size reduction? What is the incidence of “stiff atrial” syndrome and does this mitigate the clinical impact of ablation?

  11. 11

    Working in teams: What is the role of the entire heart team in AF ablation? Does a team approach achieve better outcomes than a “silo” approach?

  12. 12

    Improving the safety of catheter ablation: As ablation extends to more operators and less experienced operators, the statistical occurrence of complications will increase. We need newer techniques to minimize complications and institute standards for operators to improve the reproducibility of ablation results and safety profiles at a variety of centers worldwide.

  13. 13

    How does catheter ablation affect mortality, stroke, and hospitalization in broad and selected patient populations receiving catheter ablation for AF?

  14. 14

    Management of patients who fail initial attempts at catheter ablation: Should there be specific criteria for repeat ablations (e.g., atrial size, body mass index)? Should patients be referred for surgery for repeat ablation?

In order to address these and other important questions in the field of catheter and surgical AF ablation, we urge investigators to create and participate in multisite collaborations and electrophysiology research networks with involvement of senior and junior investigators on the steering committees to push forward the next phase of AF research. We also urge funding bodies to support these important initiatives.

Conclusion

Catheter ablation of AF is a very commonly performed procedure in hospitals throughout the world. This document provides an up-to-date review of the indications, techniques, and outcomes of catheter and surgical ablation of AF. Areas for which a consensus can be reached concerning AF ablation are identified, and a series of consensus definitions have been developed for use in future clinical trials of AF ablation. Also included within this document are recommendations concerning indications for AF ablation, technical performance of this procedure, and training. It is our hope to improve patient care by providing a foundation for those involved with care of patients with AF as well as those who perform AF ablation. It is recognized that this field continues to evolve rapidly and that this document will need to be updated. Successful AF ablation programs optimally should consist of a cooperative team of cardiologists, electrophysiologists, and surgeons to ensure appropriate indications, procedure selection, and follow-up.

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

References

  1. 1.

    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. Heart Rhythm. 2007;4(6):816–61.

    PubMed  Article  Google Scholar 

  2. 2.

    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. Heart Rhythm. 2012;9(4):632–696.e21.

    PubMed  Article  Google Scholar 

  3. 3.

    Jacobs AK, Anderson JL, Halperin JL. 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. J Am Coll Cardiol. 2014;64(13):1373–84.

    PubMed  Article  Google Scholar 

  4. 4.

    Anderson JL. Evolution of the ACC/AHA clinical practice guidelines in perspective: guiding the guidelines. J Am Coll Cardiol. 2015;65(25):2735–8.

    PubMed  Article  Google Scholar 

  5. 5.

    January CT, 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. J Am Coll Cardiol. 2014;64(21):e1–e76.

    PubMed  Article  Google Scholar 

  6. 6.

    Kirchhof P, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg. 2016;50(5):e1–e88.

    PubMed  Article  Google Scholar 

  7. 7.

    Jais P, et al. Catheter ablation versus antiarrhythmic drugs for atrial fibrillation: the A4 study. Circulation. 2008;18(24):2498–505.

    Article  Google Scholar 

  8. 8.

    Calkins H, et al. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses. Circ Arrhythm Electrophysiol. 2009;2(4):349–61.

    CAS  PubMed  Article  Google Scholar 

  9. 9.

    Packer DL, et al. Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the north American Arctic front (STOP AF) pivotal trial. J Am Coll Cardiol. 2013;61(16):1713–23.

    PubMed  Article  Google Scholar 

  10. 10.

    Kuck KH, et al. Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation. N Engl J Med. 2016;374(23):2235–45.

    PubMed  Article  Google Scholar 

  11. 11.

    Dukkipati SR, et al. Pulmonary vein isolation using the visually guided laser balloon: a prospective, multicenter, and randomized comparison to standard radiofrequency ablation. J Am Coll Cardiol. 2015;66(12):1350–60.

    PubMed  Article  Google Scholar 

  12. 12.

    Reddy VY, 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. Circulation. 2015;132(10):907–15.

    PubMed  Article  Google Scholar 

  13. 13.

    Natale A, et al. Paroxysmal AF catheter ablation with a contact force sensing catheter: results of the prospective, multicenter SMART-AF trial. J Am Coll Cardiol. 2014;64(7):647–56.

    PubMed  Article  Google Scholar 

  14. 14.

    Wilber DJ, et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA. 2010;303(4):333–40.

    CAS  PubMed  Article  Google Scholar 

  15. 15.

    Sohara H, et al. HotBalloon ablation of the pulmonary veins for paroxysmal AF: a multicenter randomized trial in Japan. J Am Coll Cardiol. 2016;68(25):2747–57.

    PubMed  Article  Google Scholar 

  16. 16.

    Pappone C, et al. A randomized trial of circumferential pulmonary vein ablation versus antiarrhythmic drug therapy in paroxysmal atrial fibrillation: the APAF study. J Am Coll Cardiol. 2006;48(11):2340–7.

    CAS  PubMed  Article  Google Scholar 

  17. 17.

    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). Eur Heart J. 2006;27(2):216–21.

    PubMed  Article  Google Scholar 

  18. 18.

    Forleo GB, 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. J Cardiovasc Electrophysiol. 2009;20(1):22–8.

    PubMed  Article  Google Scholar 

  19. 19.

    Verma A, et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med. 2015;372(19):1812–22.

    PubMed  Article  Google Scholar 

  20. 20.

    Scherr D, et al. Five-year outcome of catheter ablation of persistent atrial fibrillation using termination of atrial fibrillation as a procedural endpoint. Circ Arrhythm Electrophysiol. 2015;8(1):18–24.

    CAS  PubMed  Article  Google Scholar 

  21. 21.

    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. Circ Arrhythm Electrophysiol. 2009;2(1):35–40.

    PubMed  Article  Google Scholar 

  22. 22.

    Hummel J, et al. Phased RF ablation in persistent atrial fibrillation. Heart Rhythm. 2014;11(2):202–9.

    PubMed  Article  Google Scholar 

  23. 23.

    Bassiouny M, et al. Randomized study of persistent atrial fibrillation ablation: ablate in sinus rhythm versus ablate complex-fractionated atrial electrograms in atrial fibrillation. Circ Arrhythm Electrophysiol. 2016;9(2):e003596.

    PubMed  Article  Google Scholar 

  24. 24.

    Krittayaphong R, et al. A randomized clinical trial of the efficacy of radiofrequency catheter ablation and amiodarone in the treatment of symptomatic atrial fibrillation. J Med Assoc Thail. 2003;86(Suppl 1):S8–S16.

    Google Scholar 

  25. 25.

    Oral H, et al. Circumferential pulmonary-vein ablation for chronic atrial fibrillation. N Engl J Med. 2006;354(9):934–41.

    CAS  PubMed  Article  Google Scholar 

  26. 26.

    Mont L, et al. Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study). Eur Heart J. 2014;35(8):501–7.

    PubMed  Article  Google Scholar 

  27. 27.

    Calvo N, et al. Efficacy of circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes. Europace. 2010;12(1):30–6.

    PubMed  Article  Google Scholar 

  28. 28.

    Furlanello F, et al. Radiofrequency catheter ablation of atrial fibrillation in athletes referred for disabling symptoms preventing usual training schedule and sport competition. J Cardiovasc Electrophysiol. 2008;19(5):457–62.

    PubMed  Article  Google Scholar 

  29. 29.

    Wazni OM, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. JAMA. 2005;293(21):2634–40.

    CAS  PubMed  Article  Google Scholar 

  30. 30.

    Cosedis Nielsen J, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012;367(17):1587–95.

    PubMed  Article  CAS  Google Scholar 

  31. 31.

    Morillo CA, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. JAMA. 2014;311(7):692–700.

    CAS  PubMed  Article  Google Scholar 

  32. 32.

    Hakalahti A, et al. Radiofrequency ablation vs antiarrhythmic drug therapy as first line treatment of symptomatic atrial fibrillation: systematic review and meta-analysis. Europace. 2015;17(3):370–8.

    PubMed  Article  Google Scholar 

  33. 33.

    Hocini M, et al. Reverse remodeling of sinus node function after catheter ablation of atrial fibrillation in patients with prolonged sinus pauses. Circulation. 2003;108(10):1172–5.

    PubMed  Article  Google Scholar 

  34. 34.

    Chen YW, et al. Pacing or ablation: which is better for paroxysmal atrial fibrillation-related tachycardia-bradycardia syndrome? Pacing Clin Electrophysiol. 2014;37(4):403–11.

    PubMed  Article  Google Scholar 

  35. 35.

    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. Europace. 2014;16(2):208–13.

    PubMed  Article  Google Scholar 

  36. 36.

    Chen MS, et al. Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function. J Am Coll Cardiol. 2004;43(6):1004–9.

    PubMed  Article  Google Scholar 

  37. 37.

    Gentlesk PJ, et al. Reversal of left ventricular dysfunction following ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2007;18(1):9–14.

    PubMed  Article  Google Scholar 

  38. 38.

    Khan MN, et al. Pulmonary-vein isolation for atrial fibrillation in patients with HF. N Engl J Med. 2008;359(17):1778–85.

    CAS  PubMed  Article  Google Scholar 

  39. 39.

    MacDonald MR, et al. Radiofrequency ablation for persistent atrial fibrillation in patients with advanced heart failure and severe left ventricular systolic dysfunction: a randomised controlled trial. Heart. 2011;97(9):740–7.

    PubMed  Article  Google Scholar 

  40. 40.

    Hunter RJ, et al. A randomized controlled trial of catheter ablation versus medical treatment of atrial fibrillation in heart failure (the CAMTAF trial). Circ Arrhythm Electrophysiol. 2014;7(1):31–8.

    CAS  PubMed  Article  Google Scholar 

  41. 41.

    Tondo C, et al. Pulmonary vein vestibule ablation for the control of atrial fibrillation in patients with impaired left ventricular function. Pacing Clin Electrophysiol. 2006;29(9):962–70.

    PubMed  Article  Google Scholar 

  42. 42.

    Lutomsky BA, 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. Europace. 2008;10(5):593–9.

    PubMed  Article  Google Scholar 

  43. 43.

    Choi AD, et al. Ablation vs medical therapy in the setting of symptomatic atrial fibrillation and left ventricular dysfunction. Congest Heart Fail. 2010;16(1):10–4.

    PubMed  Article  Google Scholar 

  44. 44.

    De Potter T, et al. Left ventricular systolic dysfunction by itself does not influence outcome of atrial fibrillation ablation. Europace. 2010;12(1):24–9.

    PubMed  Article  Google Scholar 

  45. 45.

    Cha YM, et al. Success of ablation for atrial fibrillation in isolated left ventricular diastolic dysfunction: a comparison to systolic dysfunction and normal ventricular function. Circ Arrhythm Electrophysiol. 2011;4(5):724–32.

    PubMed  Article  Google Scholar 

  46. 46.

    Jones DG, et al. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in HF. J Am Coll Cardiol. 2013;61(18):1894–903.

    PubMed  Article  Google Scholar 

  47. 47.

    Machino-Ohtsuka T, et al. Efficacy, safety, and outcomes of catheter ablation of atrial fibrillation in patients with heart failure with preserved ejection fraction. J Am Coll Cardiol. 2013;62(20):1857–65.

    PubMed  Article  Google Scholar 

  48. 48.

    Al Halabi S, et al. Catheter ablation for atrial fibrillation in heart failure patients: a meta-analysis of randomized controlled trials. JACC Clin Electrophysiol. 2015;1(3):200–9.

    PubMed  PubMed Central  Article  Google Scholar 

  49. 49.

    Bunch TJ, et al. Five-year outcomes of catheter ablation in patients with atrial fibrillation and left ventricular systolic dysfunction. J Cardiovasc Electrophysiol. 2015;26(4):363–70.

    PubMed  Article  Google Scholar 

  50. 50.

    Lobo TJ, et al. Atrial fibrillation ablation in systolic dysfunction: clinical and echocardiographic outcomes. Arq Bras Cardiol. 2015;104(1):45–52.

    PubMed  PubMed Central  Google Scholar 

  51. 51.

    Ling LH, 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. Heart Rhythm. 2013;10(9):1334–9.

    PubMed  Article  Google Scholar 

  52. 52.

    Hsu LF, et al. Catheter ablation for atrial fibrillation in congestive HF. N Engl J Med. 2004;351(23):2373–83.

    CAS  PubMed  Article  Google Scholar 

  53. 53.

    Spragg DD, et al. Complications of catheter ablation for atrial fibrillation: incidence and predictors. J Cardiovasc Electrophysiol. 2008;19(6):627–31.

    PubMed  Article  Google Scholar 

  54. 54.

    Kusumoto F, et al. Radiofrequency catheter ablation of atrial fibrillation in older patients: outcomes and complications. J Interv Card Electrophysiol. 2009;25(1):31–5.

    PubMed  Article  Google Scholar 

  55. 55.

    Bunch TJ, et al. Long-term clinical efficacy and risk of catheter ablation for atrial fibrillation in octogenarians. Pacing Clin Electrophysiol. 2010;33(2):146–52.

    PubMed  Article  Google Scholar 

  56. 56.

    Santangeli P, et al. Catheter ablation of atrial fibrillation in octogenarians: safety and outcomes. J Cardiovasc Electrophysiol. 2012;23(7):687–93.

    PubMed  Article  Google Scholar 

  57. 57.

    Nademanee K, et al. Benefits and risks of catheter ablation in elderly patients with atrial fibrillation. Heart Rhythm. 2015;12(1):44–51.

    PubMed  Article  Google Scholar 

  58. 58.

    Bunch TJ, et al. The impact of age on 5-year outcomes after atrial fibrillation catheter ablation. J Cardiovasc Electrophysiol. 2016;27(2):141–6.

    PubMed  Article  Google Scholar 

  59. 59.

    Metzner I, et al. Ablation of atrial fibrillation in patients >/=75 years: long-term clinical outcome and safety. Europace. 2016;18(4):543–9.

    PubMed  Article  Google Scholar 

  60. 60.

    Bunch TJ, et al. Substrate and procedural predictors of outcomes after catheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy. J Cardiovasc Electrophysiol. 2008;19(10):1009–14.

    PubMed  Article  Google Scholar 

  61. 61.

    Olivotto I, et al. Impact of atrial fibrillation on the clinical course of hypertrophic cardiomyopathy. Circulation. 2001;104(21):2517–24.

    CAS  PubMed  Article  Google Scholar 

  62. 62.

    Providencia R, et al. Catheter ablation for atrial fibrillation in hypertrophic cardiomyopathy: a systematic review and meta-analysis. Heart. 2016;102(19):1533–43.

    CAS  PubMed  Article  Google Scholar 

  63. 63.

    Leong-Sit P, et al. Efficacy and risk of atrial fibrillation ablation before 45 years of age. Circ Arrhythm Electrophysiol. 2010;3(5):452–7.

    PubMed  Article  Google Scholar 

  64. 64.

    Chun KR, et al. Catheter ablation of atrial fibrillation in the young: insights from the German ablation registry. Clin Res Cardiol. 2013;102(6):459–68.

    PubMed  Article  Google Scholar 

  65. 65.

    Koopman P, et al. Efficacy of radiofrequency catheter ablation in athletes with atrial fibrillation. Europace. 2011;13(10):1386–93.

    PubMed  Article  Google Scholar 

  66. 66.

    Forleo GB, 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. Int J Cardiol. 2013;168(4):3968–70.

    PubMed  Article  Google Scholar 

  67. 67.

    Wu L, et al. Comparison of radiofrequency catheter ablation between asymptomatic and symptomatic persistent atrial fibrillation: a propensity score matched analysis. J Cardiovasc Electrophysiol. 2016;27(5):531–5.

    PubMed  Article  Google Scholar 

  68. 68.

    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. J Cardiovasc Electrophysiol. 2014;25(10):1057–64.

    PubMed  Article  Google Scholar 

  69. 69.

    U.S. Food and Drug Administration.Summary of Safety and Effectiveness Data: AtriCure Synergy Ablation System, PMA P100046. 2011.

  70. 70.

    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. Ann Thorac Surg. 2016;101(6):2265–71.

    PubMed  Article  Google Scholar 

  71. 71.

    Abreu Filho CA, et al. Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease. Circulation. 2005;112(9 Suppl):I20–5.

    PubMed  Google Scholar 

  72. 72.

    Doukas G, et al. Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: a randomized controlled trial. JAMA. 2005;294(18):2323–9.

    CAS  PubMed  Article  Google Scholar 

  73. 73.

    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). Eur Heart J. 2007;28(23):2902–8.

    PubMed  Article  Google Scholar 

  74. 74.

    Chevalier P, et al. Left atrial radiofrequency ablation during mitral valve surgery: a prospective randomized multicentre study (SAFIR). Arch Cardiovasc Dis. 2009;102(11):769–75.

    PubMed  Article  Google Scholar 

  75. 75.

    Cheng DC, et al. Surgical ablation for atrial fibrillation in cardiac surgery: a meta-analysis and systematic review. Innovations (Phila). 2010;5(2):84–96.

    Article  Google Scholar 

  76. 76.

    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. Eur Heart J. 2012;33(21):2644–52.

    PubMed  PubMed Central  Article  Google Scholar 

  77. 77.

    Phan K, et al. Surgical ablation for treatment of atrial fibrillation in cardiac surgery: a cumulative meta-analysis of randomised controlled trials. Heart. 2014;100(9):722–30.

    PubMed  Article  Google Scholar 

  78. 78.

    Gillinov AM, et al. Surgical ablation of atrial fibrillation during mitral-valve surgery. N Engl J Med. 2015;372(15):1399–409.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  79. 79.

    Rankin JS, et al. The society of thoracic surgeons risk model for operative mortality after multiple valve surgery. Ann Thorac Surg. 2013;95(4):1484–90.

    PubMed  Article  Google Scholar 

  80. 80.

    Louagie Y, et al. Improved patient survival with concomitant cox maze III procedure compared with heart surgery alone. Ann Thorac Surg. 2009;87(2):440–6.

    PubMed  Article  Google Scholar 

  81. 81.

    Chiappini B, Di Bartolomeo R, Marinelli G. Radiofrequency ablation for atrial fibrillation: different approaches. Asian Cardiovasc Thorac Ann. 2004;12(3):272–7.

    PubMed  Article  Google Scholar 

  82. 82.

    Barnett SD, Ad N. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. J Thorac Cardiovasc Surg. 2006;131(5):1029–35.

    PubMed  Article  Google Scholar 

  83. 83.

    Edgerton JR, Jackman WM, Mack MJ. A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set. Ann Thorac Surg. 2009;88(5):1655–7.

    PubMed  Article  Google Scholar 

  84. 84.

    Edgerton JR, et al. Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the “Dallas” lesion set. Heart Rhythm. 2009;6(12 Suppl):S64–70.

    PubMed  Article  Google Scholar 

  85. 85.

    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. Heart Rhythm. 2009;6(12 Suppl):S50–63.

    PubMed  Article  Google Scholar 

  86. 86.

    Malaisrie SC, et al. Atrial fibrillation ablation in patients undergoing aortic valve replacement. J Heart Valve Dis. 2012;21(3):350–7.

    PubMed  Google Scholar 

  87. 87.

    Cherniavsky A, et al. Assessment of results of surgical treatment for persistent atrial fibrillation during coronary artery bypass grafting using implantable loop recorders. Interact Cardiovasc Thorac Surg. 2014;18(6):727–31.

    PubMed  Article  Google Scholar 

  88. 88.

    Yoo JS, et al. Impact of concomitant surgical atrial fibrillation ablation in patients undergoing aortic valve replacement. Circ J. 2014;78(6):1364–71.

    PubMed  Article  Google Scholar 

  89. 89.

    Driessen AH, et al. Ganglion plexus ablation in advanced atrial fibrillation: the AFACT study. J Am Coll Cardiol. 2016;68(11):1155–65.

    PubMed  Article  Google Scholar 

  90. 90.

    Boersma LV, et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial. Circulation. 2012;125(1):23–30.

    PubMed  Article  Google Scholar 

  91. 91.

    Henn MC, et al. Late outcomes after the Cox maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg. 2015;150(5):1168–76. 1178 e1–2

    PubMed  PubMed Central  Article  Google Scholar 

  92. 92.

    Krul SP, et al. Navigating the mini-maze: systematic review of the first results and progress of minimally-invasive surgery in the treatment of atrial fibrillation. Int J Cardiol. 2013;166(1):132–40.

    PubMed  Article  Google Scholar 

  93. 93.

    Cox JL, et al. The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg. 1991;101(4):569–83.

    CAS  PubMed  Google Scholar 

  94. 94.

    Rodriguez E, et al. Minimally invasive bi-atrial CryoMaze operation for atrial fibrillation. Oper Tech Thorac Cardiovasc Surg. 2009;14(3):208–23.

    Article  Google Scholar 

  95. 95.

    Wolf RK, et al. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg. 2005;130(3):797–802.

    PubMed  Article  Google Scholar 

  96. 96.

    Edgerton JR, et al. Minimally invasive pulmonary vein isolation and partial autonomic denervation for surgical treatment of atrial fibrillation. Ann Thorac Surg. 2008;86(1):35–8. discussion 39

    PubMed  Article  Google Scholar 

  97. 97.

    Edgerton JR, et al. Minimally invasive surgical ablation of atrial fibrillation: six-month results. J Thorac Cardiovasc Surg. 2009;138(1):109–13. discussion 114

    PubMed  Article  Google Scholar 

  98. 98.

    Beyer E, Lee R, Lam BK. Point: minimally invasive bipolar radiofrequency ablation of lone atrial fibrillation: early multicenter results. J Thorac Cardiovasc Surg. 2009;137(3):521–6.

    PubMed  Article  Google Scholar 

  99. 99.

    Kearney K, et al. A systematic review of surgical ablation versus catheter ablation for atrial fibrillation. Ann Cardiothorac Surg. 2014;3(1):15–29.

    PubMed  PubMed Central  Google Scholar 

  100. 100.

    Ad N, et al. Surgical ablation of atrial fibrillation trends and outcomes in North America. J Thorac Cardiovasc Surg. 2012;144(5):1051–60.

    PubMed  Article  Google Scholar 

  101. 101.

    Driessen AH, et al. Electrophysiologically guided thoracoscopic surgery for advanced atrial fibrillation: 5-year follow-up. J Am Coll Cardiol. 2017;69(13):1753–4.

    PubMed  Article  Google Scholar 

  102. 102.

    Khargi K, et al. Surgical treatment of atrial fibrillation; a systematic review. Eur J Cardiothorac Surg. 2005;27(2):258–65.

    PubMed  Article  Google Scholar 

  103. 103.

    Wazni OM, et al. Atrial arrhythmias after surgical maze: findings during catheter ablation. J Am Coll Cardiol. 2006;48(7):1405–9.

    PubMed  Article  Google Scholar 

  104. 104.

    Magnano AR, et al. Mechanisms of atrial tachyarrhythmias following surgical atrial fibrillation ablation. J Cardiovasc Electrophysiol. 2006;17(4):366–73.

    PubMed  Article  Google Scholar 

  105. 105.

    McElderry HT, et al. Proarrhythmic aspects of atrial fibrillation surgery: mechanisms of postoperative macroreentrant tachycardias. Circulation. 2008;117(2):155–62.

    PubMed  Article  Google Scholar 

  106. 106.

    McCarthy PM, et al. Where does atrial fibrillation surgery fail? Implications for increasing effectiveness of ablation. J Thorac Cardiovasc Surg. 2010;139(4):860–7.

    PubMed  Article  Google Scholar 

  107. 107.

    Zeng Y, et al. Recurrent atrial arrhythmia after minimally invasive pulmonary vein isolation for atrial fibrillation. Ann Thorac Surg. 2010;90(2):510–5.

    PubMed  Article  Google Scholar 

  108. 108.

    Lee R, et al. Surgical treatment for isolated atrial fibrillation: minimally invasive vs. classic cut and sew maze. Innovations (Phila). 2011;6(6):373–7.

    Article  Google Scholar 

  109. 109.

    Kuck KH, et al. Impact of complete versus incomplete circumferential lines around the pulmonary veins during catheter ablation of paroxysmal atrial fibrillation: results from the gap-atrial fibrillation-German atrial fibrillation competence network 1 trial. Circ Arrhythm Electrophysiol. 2016;9(1):e003337.

    PubMed  Article  Google Scholar 

  110. 110.

    Verma A, et al. Response of atrial fibrillation to pulmonary vein antrum isolation is directly related to resumption and delay of pulmonary vein conduction. Circulation. 2005;112(5):627–35.

    PubMed  Article  Google Scholar 

  111. 111.

    Macle L, et al. Adenosine-guided pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation: an international, multicentre, randomised superiority trial. Lancet. 2015;386(9994):672–9.

    PubMed  Article  Google Scholar 

  112. 112.

    Cheema A, et al. Incidence and time course of early recovery of pulmonary vein conduction after catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2007;18(4):387–91.

    PubMed  Article  Google Scholar 

  113. 113.

    Rajappan K, et al. Acute and chronic pulmonary vein reconnection after atrial fibrillation ablation: a prospective characterization of anatomical sites. Pacing Clin Electrophysiol. 2008;31(12):1598–605.

    PubMed  Article  Google Scholar 

  114. 114.

    Bansch D, et al. Circumferential pulmonary vein isolation: wait or stop early after initial successful pulmonary vein isolation? Europace. 2013;15(2):183–8.

    PubMed  Article  Google Scholar 

  115. 115.

    Nakamura K, et al. Optimal observation time after completion of circumferential pulmonary vein isolation for atrial fibrillation to prevent chronic pulmonary vein reconnections. Int J Cardiol. 2013;168(6):5300–10.

    PubMed  Article  Google Scholar 

  116. 116.

    Wang XH, et al. Early identification and treatment of PV re-connections: role of observation time and impact on clinical results of atrial fibrillation ablation. Europace. 2007;9(7):481–6.

    PubMed  Article  Google Scholar 

  117. 117.

    Sauer WH, et al. Atrioventricular nodal reentrant tachycardia in patients referred for atrial fibrillation ablation: response to ablation that incorporates slow-pathway modification. Circulation. 2006;114(3):191–5.

    PubMed  Article  Google Scholar 

  118. 118.

    Ninomiya Y, et al. Usefulness of the adenosine triphosphate with a sufficient observation period for detecting reconduction after pulmonary vein isolation. Pacing Clin Electrophysiol. 2009;32(10):1307–12.

    PubMed  Article  Google Scholar 

  119. 119.

    Yamane T, et al. Repeated provocation of time- and ATP-induced early pulmonary vein reconnections after pulmonary vein isolation: eliminating paroxysmal atrial fibrillation in a single procedure. Circ Arrhythm Electrophysiol. 2011;4(5):601–8.

    PubMed  Article  Google Scholar 

  120. 120.

    Kobori A, et al. Adenosine triphosphate-guided pulmonary vein isolation for atrial fibrillation: the UNmasking dormant electrical Reconduction by adenosine TriPhosphate (UNDER-ATP) trial. Eur Heart J. 2015;36(46):3276–87.

    PubMed  Google Scholar 

  121. 121.

    Pratola C, et al. Radiofrequency ablation of atrial fibrillation: is the persistence of all intraprocedural targets necessary for long-term maintenance of sinus rhythm? Circulation. 2008;117(2):136–43.

    PubMed  Article  Google Scholar 

  122. 122.

    Jiang RH, et al. Incidence of pulmonary vein conduction recovery in patients without clinical recurrence after ablation of paroxysmal atrial fibrillation: mechanistic implications. Heart Rhythm. 2014;11(6):969–76.

    PubMed  Article  Google Scholar 

  123. 123.

    Arentz T, et al. “Dormant” pulmonary vein conduction revealed by adenosine after ostial radiofrequency catheter ablation. J Cardiovasc Electrophysiol. 2004;15(9):1041–7.

    PubMed  Article  Google Scholar 

  124. 124.

    Tritto M, et al. Adenosine restores atrio-venous conduction after apparently successful ostial isolation of the pulmonary veins. Eur Heart J. 2004;25(23):2155–63.

    CAS  PubMed  Article  Google Scholar 

  125. 125.

    Datino T, et al. Mechanisms by which adenosine restores conduction in dormant canine pulmonary veins. Circulation. 2010;121(8):963–72.

    CAS  PubMed  Article  Google Scholar 

  126. 126.

    Dallaglio PD, et al. The role of adenosine in pulmonary vein isolation: a critical review. Cardiol Res Pract. 2016;2016:8632509.

    PubMed  PubMed Central  Article  Google Scholar 

  127. 127.

    Kapa S, et al. Dose-dependent pulmonary vein reconnection in response to adenosine: relevance of atrioventricular block during infusion. J Interv Card Electrophysiol. 2016;47(1):117–23.

    PubMed  Article  Google Scholar 

  128. 128.

    Andrade JG, et al. Pulmonary vein isolation using “contact force” ablation: the effect on dormant conduction and long-term freedom from recurrent atrial fibrillation–a prospective study. Heart Rhythm. 2014;11(11):1919–24.

    PubMed  Article  Google Scholar 

  129. 129.

    Eitel C, et al. Circumferential pulmonary vein isolation and linear left atrial ablation as a single-catheter technique to achieve bidirectional conduction block: the pace-and-ablate approach. Heart Rhythm. 2010;7(2):157–64.

    PubMed  Article  Google Scholar 

  130. 130.

    Steven D, et al. Loss of pace capture on the ablation line: a new marker for complete radiofrequency lesions to achieve pulmonary vein isolation. Heart Rhythm. 2010;7(3):323–30.

    PubMed  Article  Google Scholar 

  131. 131.

    Andrade JG, et al. Pulmonary vein isolation using a pace-capture-guided versus an adenosine-guided approach: effect on dormant conduction and long-term freedom from recurrent atrial fibrillation–a prospective study. Circ Arrhythm Electrophysiol. 2013;6(6):1103–8.

    PubMed  Article  Google Scholar 

  132. 132.

    Steven D, et al. Benefit of pulmonary vein isolation guided by loss of pace capture on the ablation line: results from a prospective 2-center randomized trial. J Am Coll Cardiol. 2013;62(1):44–50.

    PubMed  Article  Google Scholar 

  133. 133.

    Schaeffer B, et al. Loss of pace capture on the ablation line during pulmonary vein isolation versus “dormant conduction”: is adenosine expendable? J Cardiovasc Electrophysiol. 2015;26(10):1075–80.

    PubMed  Article  Google Scholar 

  134. 134.

    Gerstenfeld EP, et al. Utility of exit block for identifying electrical isolation of the pulmonary veins. J Cardiovasc Electrophysiol. 2002;13(10):971–9.

    PubMed  Article  Google Scholar 

  135. 135.

    Vijayaraman P, et al. Assessment of exit block following pulmonary vein isolation: far-field capture masquerading as entrance without exit block. Heart Rhythm. 2012;9(10):1653–9.

    PubMed  Article  Google Scholar 

  136. 136.

    Ip JE, et al. Method for differentiating left superior pulmonary vein exit conduction from pseudo-exit conduction. Pacing Clin Electrophysiol. 2013;36(3):299–308.

    PubMed  Article  Google Scholar 

  137. 137.

    Spector P. Principles of cardiac electric propagation and their implications for re-entrant arrhythmias. Circ Arrhythm Electrophysiol. 2013;6(3):655–61.

    PubMed  Article  Google Scholar 

  138. 138.

    Chen S, et al. Blocking the pulmonary vein to left atrium conduction in addition to the entrance block enhances clinical efficacy in atrial fibrillation ablation. Pacing Clin Electrophysiol. 2012;35(5):524–31.

    PubMed  Article  Google Scholar 

  139. 139.

    Kim JY, et al. Achievement of successful pulmonary vein isolation: methods of adenosine testing and incremental benefit of exit block. J Interv Card Electrophysiol. 2016;46(3):315–24.

    PubMed  Article  Google Scholar 

  140. 140.

    Perez FJ, et al. Long-term outcomes after catheter ablation of cavo-tricuspid isthmus dependent atrial flutter: a meta-analysis. Circ Arrhythm Electrophysiol. 2009;2(4):393–401.

    PubMed  Article  Google Scholar 

  141. 141.

    Patel NJ, et al. Contemporary utilization and safety outcomes of catheter ablation of atrial flutter in the United States: analysis of 89,638 procedures. Heart Rhythm. 2016;13(6):1317–25.

    PubMed  Article  Google Scholar 

  142. 142.

    Wazni O, et al. Randomized study comparing combined pulmonary vein-left atrial junction disconnection and cavotricuspid isthmus ablation versus pulmonary vein-left atrial junction disconnection alone in patients presenting with typical atrial flutter and atrial fibrillation. Circulation. 2003;108(20):2479–83.

    PubMed  Article  Google Scholar 

  143. 143.

    Natale A, et al. Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter. J Am Coll Cardiol. 2000;35(7):1898–904.

    CAS  PubMed  Article  Google Scholar 

  144. 144.

    Pappone C, et al. Prevention of iatrogenic atrial tachycardia after ablation of atrial fibrillation: a prospective randomized study comparing circumferential pulmonary vein ablation with a modified approach. Circulation. 2004;110(19):3036–42.

    PubMed  Article  Google Scholar 

  145. 145.

    Sawhney N, et al. Circumferential pulmonary vein ablation with additional linear ablation results in an increased incidence of left atrial flutter compared with segmental pulmonary vein isolation as an initial approach to ablation of paroxysmal atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3(3):243–8.

    PubMed  Article  Google Scholar 

  146. 146.

    Chae S, et al. Atrial tachycardia after circumferential pulmonary vein ablation of atrial fibrillation: mechanistic insights, results of catheter ablation, and risk factors for recurrence. J Am Coll Cardiol. 2007;50(18):1781–7.

    PubMed  Article  Google Scholar 

  147. 147.

    Ouyang F, et al. Characterization of reentrant circuits in left atrial macroreentrant tachycardia: critical isthmus block can prevent atrial tachycardia recurrence. Circulation. 2002;105(16):1934–42.

    PubMed  Article  Google Scholar 

  148. 148.

    Matsuo S, et al. Peri-mitral atrial flutter in patients with atrial fibrillation ablation. Heart Rhythm. 2010;7(1):2–8.

    PubMed  Article  Google Scholar 

  149. 149.

    Tzeis S, et al. The modified anterior line: an alternative linear lesion in perimitral flutter. J Cardiovasc Electrophysiol. 2010;21(6):665–70.

    PubMed  Article  Google Scholar 

  150. 150.

    Chen SA, Tai CT. Catheter ablation of atrial fibrillation originating from the non-pulmonary vein foci. J Cardiovasc Electrophysiol. 2005;16(2):229–32.

    PubMed  Article  Google Scholar 

  151. 151.

    Haissaguerre M, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339(10):659–66.

    CAS  PubMed  Article  Google Scholar 

  152. 152.

    Lee SH, et al. Predictors of non-pulmonary vein ectopic beats initiating paroxysmal atrial fibrillation: implication for catheter ablation. J Am Coll Cardiol. 2005;46(6):1054–9.

    PubMed  Article  Google Scholar 

  153. 153.

    Hsieh MH, et al. Alterations of heart rate variability after radiofrequency catheter ablation of focal atrial fibrillation originating from pulmonary veins. Circulation. 1999;100(22):2237–43.

    CAS  PubMed  Article  Google Scholar 

  154. 154.

    Shah D, et al. Nonpulmonary vein foci: do they exist? Pacing Clin Electrophysiol. 2003;26(7 Pt 2):1631–5.

    PubMed  Article  Google Scholar 

  155. 155.

    Lin D, et al. Provocability of atrial fibrillation triggers during pulmonary vein isolation in patients with infrequent AF [abstract]. Heart Rhythm. 2004;1(Suppl):S231.

    Google Scholar 

  156. 156.

    Di Biase L, et al. Left atrial appendage: an underrecognized trigger site of atrial fibrillation. Circulation. 2010;122(2):109–18.

    PubMed  Article  Google Scholar 

  157. 157.

    Santangeli P, et al. Prevalence and distribution of focal triggers in persistent and long-standing persistent atrial fibrillation. Heart Rhythm. 2016;13(2):374–82.

    PubMed  Article  Google Scholar 

  158. 158.

    Lin WS, et al. Catheter ablation of paroxysmal atrial fibrillation initiated by non-pulmonary vein ectopy. Circulation. 2003;107(25):3176–83.

    PubMed  Article  Google Scholar 

  159. 159.

    Lee RJ, et al. Percutaneous alternative to the maze procedure for the treatment of persistent or long-standing persistent atrial fibrillation (aMAZE trial): rationale and design. Am Heart J. 2015;170(6):1184–94.

    PubMed  Article  Google Scholar 

  160. 160.

    Zhao Y, et al. Importance of non-pulmonary vein triggers ablation to achieve long-term freedom from paroxysmal atrial fibrillation in patients with low ejection fraction. Heart Rhythm. 2016;13(1):141–9.

    PubMed  Article  Google Scholar 

  161. 161.

    Dixit S, et al. Randomized ablation strategies for the treatment of persistent atrial fibrillation: RASTA study. Circ Arrhythm Electrophysiol. 2012;5(2):287–94.

    PubMed  Article  Google Scholar 

  162. 162.

    Neuzil P, et al. Electrical reconnection after pulmonary vein isolation is contingent on contact force during initial treatment: results from the EFFICAS I study. Circ Arrhythm Electrophysiol. 2013;6(2):327–33.

    PubMed  Article  Google Scholar 

  163. 163.

    Yokoyama K, et al. Novel contact force sensor incorporated in irrigated radiofrequency ablation catheter predicts lesion size and incidence of steam pop and thrombus. Circ Arrhythm Electrophysiol. 2008;1(5):354–62.

    PubMed  Article  Google Scholar 

  164. 164.

    Ikeda A, et al. Relationship between catheter contact force and radiofrequency lesion size and incidence of steam pop in the beating canine heart: electrogram amplitude, impedance, and electrode temperature are poor predictors of electrode-tissue contact force and lesion size. Circ Arrhythm Electrophysiol. 2014;7(6):1174–80.

    PubMed  Article  Google Scholar 

  165. 165.

    Nakagawa H, et al. Locations of high contact force during left atrial mapping in atrial fibrillation patients: electrogram amplitude and impedance are poor predictors of electrode-tissue contact force for ablation of atrial fibrillation. Circ Arrhythm Electrophysiol. 2013;6(4):746–53.

    PubMed  Article  Google Scholar 

  166. 166.

    Nakagawa H, et al. Prospective study to test the ability to create RF lesions at predicted depth and diameter using a new formula incorporating contact force, radiofrequency power and application time (force-power-time index) in the beating heart [abstract]. Heart Rhythm. 2014;11(Suppl):S548.

    Google Scholar 

  167. 167.

    Kumar S, et al. Predictive value of impedance changes for real-time contact force measurements during catheter ablation of atrial arrhythmias in humans. Heart Rhythm. 2013;10(7):962–9.

    PubMed  Article  Google Scholar 

  168. 168.

    Kumar S, et al. Prospective characterization of catheter-tissue contact force at different anatomic sites during antral pulmonary vein isolation. Circ Arrhythm Electrophysiol. 2012;5(6):1124–9.

    PubMed  Article  Google Scholar 

  169. 169.

    Reddy VY, et al. The relationship between contact force and clinical outcome during radiofrequency catheter ablation of atrial fibrillation in the TOCCATA study. Heart Rhythm. 2012;9(11):1789–95.

    PubMed  Article  Google Scholar 

  170. 170.

    Haldar S, et al. Contact force sensing technology identifies sites of inadequate contact and reduces acute pulmonary vein reconnection: a prospective case control study. Int J Cardiol. 2013;168(2):1160–6.

    PubMed  Article  Google Scholar 

  171. 171.

    Perna F, et al. Assessment of catheter tip contact force resulting in cardiac perforation in swine atria using force sensing technology. Circ Arrhythm Electrophysiol. 2011;4(2):218–24.

    PubMed  Article  Google Scholar 

  172. 172.

    Kimura M, et al. Comparison of lesion formation between contact force-guided and non-guided circumferential pulmonary vein isolation: a prospective, randomized study. Heart Rhythm. 2014;11(6):984–91.

    PubMed  Article  Google Scholar 

  173. 173.

    Sohns C, et al. Quantitative magnetic resonance imaging analysis of the relationship between contact force and left atrial scar formation after catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2014;25(2):138–45.

    PubMed  Article  Google Scholar 

  174. 174.

    Martinek M, et al. Clinical impact of an open-irrigated radiofrequency catheter with direct force measurement on atrial fibrillation ablation. Pacing Clin Electrophysiol. 2012;35(11):1312–8.

    PubMed  Article  Google Scholar 

  175. 175.

    Marijon E, et al. Real-time contact force sensing for pulmonary vein isolation in the setting of paroxysmal atrial fibrillation: procedural and 1-year results. J Cardiovasc Electrophysiol. 2014;25(2):130–7.

    PubMed  Article  Google Scholar 

  176. 176.

    Sigmund E, et al. Optimizing radiofrequency ablation of paroxysmal and persistent atrial fibrillation by direct catheter force measurement-a case-matched comparison in 198 patients. Pacing Clin Electrophysiol. 2015;38(2):201–8.

    PubMed  Article  Google Scholar 

  177. 177.

    Ullah W, et al. Randomized trial comparing pulmonary vein isolation using the SmartTouch catheter with or without real-time contact force data. Heart Rhythm. 2016;13(9):1761–7.

    PubMed  Article  Google Scholar 

  178. 178.

    Wakili R, et al. Impact of real-time contact force and impedance measurement in pulmonary vein isolation procedures for treatment of atrial fibrillation. Clin Res Cardiol. 2014;103(2):97–106.

    PubMed  Article  Google Scholar 

  179. 179.

    Kumagai K, et al. A new approach for complete isolation of the posterior left atrium including pulmonary veins for atrial fibrillation. J Cardiovasc Electrophysiol. 2007;18(10):1047–52.

    PubMed  Article  Google Scholar 

  180. 180.

    Yamaguchi Y, et al. Long-term effects of box isolation on sympathovagal balance in atrial fibrillation. Circ J. 2010;74(6):1096–103.

    PubMed  Article  Google Scholar 

  181. 181.

    Kumagai K. Catheter ablation of atrial fibrillation. State of the Art Circ J. 2011;75(10):2305–11.

    PubMed  Google Scholar 

  182. 182.

    Kim JS, et al. Does isolation of the left atrial posterior wall improve clinical outcomes after radiofrequency catheter ablation for persistent atrial fibrillation? A prospective randomized clinical trial. Int J Cardiol. 2015;181:277–83.

    PubMed  Article  Google Scholar 

  183. 183.

    He X, et al. Left atrial posterior wall isolation reduces the recurrence of atrial fibrillation: a meta-analysis. J Interv Card Electrophysiol. 2016;46(3):267–74.

    PubMed  Article  Google Scholar 

  184. 184.

    Di Biase L, et al. Left atrial appendage isolation in patients with long-standing persistent AF undergoing catheter ablation: BELIEF trial. J Am Coll Cardiol. 2016;68(18):1929–40.

    PubMed  Article  Google Scholar 

  185. 185.

    Di Biase L, et al. Ablation versus amiodarone for treatment of persistent atrial fibrillation in patients with congestive heart failure and an implanted device: results from the AATAC multicenter randomized trial. Circulation. 2016;133(17):1637–44.

    PubMed  Article  CAS  Google Scholar 

  186. 186.

    Morillo CA, et al. Chronic rapid atrial pacing. Structural, functional, and electrophysiological characteristics of a new model of sustained atrial fibrillation. Circulation. 1995;91(5):1588–95.

    CAS  PubMed  Article  Google Scholar 

  187. 187.

    Harada A, et al. Atrial activation during chronic atrial fibrillation in patients with isolated mitral valve disease. Ann Thorac Surg. 1996;61(1):104–11. discussion 111–112

    CAS  PubMed  Article  Google Scholar 

  188. 188.

    Gray RA, Pertsov AM, Jalife J. Spatial and temporal organization during cardiac fibrillation. Nature. 1998;392(6671):75–8.

    CAS  PubMed  Article  Google Scholar 

  189. 189.

    Berenfeld O, et al. Spatially distributed dominant excitation frequencies reveal hidden organization in atrial fibrillation in the Langendorff-perfused sheep heart. J Cardiovasc Electrophysiol. 2000;11(8):869–79.

    CAS  PubMed  Article  Google Scholar 

  190. 190.

    Mansour M, et al. Left-to-right gradient of atrial frequencies during acute atrial fibrillation in the isolated sheep heart. Circulation. 2001;103(21):2631–6.

    CAS  PubMed  Article  Google Scholar 

  191. 191.

    Lazar S, et al. Presence of left-to-right atrial frequency gradient in paroxysmal but not persistent atrial fibrillation in humans. Circulation. 2004;110(20):3181–6.

    PubMed  Article  Google Scholar 

  192. 192.

    Atienza F, et al. Real-time dominant frequency mapping and ablation of dominant frequency sites in atrial fibrillation with left-to-right frequency gradients predicts long-term maintenance of sinus rhythm. Heart Rhythm. 2009;6(1):33–40.

    PubMed  Article  Google Scholar 

  193. 193.

    Atienza F, et al. Comparison of radiofrequency catheter ablation of drivers and circumferential pulmonary vein isolation in atrial fibrillation: a noninferiority randomized multicenter RADAR-AF trial. J Am Coll Cardiol. 2014;64(23):2455–67.

    PubMed  Article  Google Scholar 

  194. 194.

    Vogler J, et al. Pulmonary vein isolation versus defragmentation: the CHASE-AF clinical trial. J Am Coll Cardiol. 2015;66(24):2743–52.

    PubMed  Article  Google Scholar 

  195. 195.

    Haissaguerre M, et al. Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subsequent arrhythmias. J Cardiovasc Electrophysiol. 2005;16(11):1138–47.

    PubMed  Article  Google Scholar 

  196. 196.

    Nademanee K, et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol. 2004;43(11):2044–53.

    PubMed  Article  Google Scholar 

  197. 197.

    O'Neill MD, et al. Long-term follow-up of persistent atrial fibrillation ablation using termination as a procedural endpoint. Eur Heart J. 2009;30(9):1105–12.

    PubMed  Article  Google Scholar 

  198. 198.

    Lo LW, et al. Predicting factors for atrial fibrillation acute termination during catheter ablation procedures: implications for catheter ablation strategy and long-term outcome. Heart Rhythm. 2009;6(3):311–8.

    PubMed  Article  Google Scholar 

  199. 199.

    Zhang Z, et al. Linear ablation following pulmonary vein isolation in patients with atrial fibrillation: a meta-analysis. Pacing Clin Electrophysiol. 2016;39(6):623–30.

    PubMed  Article  Google Scholar 

  200. 200.

    Kim TH, et al. Linear ablation in addition to circumferential pulmonary vein isolation (Dallas lesion set) does not improve clinical outcome in patients with paroxysmal atrial fibrillation: a prospective randomized study. Europace. 2015;17(3):388–95.

    PubMed  Article  Google Scholar 

  201. 201.

    Wynn GJ, et al. Biatrial linear ablation in sustained nonpermanent AF: results of the substrate modification with ablation and antiarrhythmic drugs in nonpermanent atrial fibrillation (SMAN-PAF) trial. Heart Rhythm. 2016;13(2):399–406.

    PubMed  Article  Google Scholar 

  202. 202.

    Kottkamp H, et al. Box isolation of fibrotic areas (BIFA): a patient-tailored substrate modification approach for ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2016;27(1):22–30.

    PubMed  Article  Google Scholar 

  203. 203.

    Kottkamp H, Bender R, Berg J. Catheter ablation of atrial fibrillation: how to modify the substrate? J Am Coll Cardiol. 2015;65(2):196–206.

    PubMed  Article  Google Scholar 

  204. 204.

    Rolf S, et al. Tailored atrial substrate modification based on low-voltage areas in catheter ablation of atrial fibrillation. Circ Arrhythm Electrophysiol. 2014;7(5):825–33.

    PubMed  Article  Google Scholar 

  205. 205.

    Bai R, et al. Proven isolation of the pulmonary vein antrum with or without left atrial posterior wall isolation in patients with persistent atrial fibrillation. Heart Rhythm. 2016;13(1):132–40.

    PubMed  Article  Google Scholar 

  206. 206.

    Cutler MJ, et al. Impact of voltage mapping to guide whether to perform ablation of the posterior wall in patients with persistent atrial fibrillation. J Cardiovasc Electrophysiol. 2016;27(1):13–21.

    PubMed  Article  Google Scholar 

  207. 207.

    Yang G, et al. Catheter ablation of nonparoxysmal atrial fibrillation using electrophysiologically guided substrate modification during sinus rhythm after pulmonary vein isolation. Circ Arrhythm Electrophysiol. 2016;9(2):e003382.

    PubMed  Article  Google Scholar 

  208. 208.

    Verma A, et al. Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation: an independent predictor of procedural failure. J Am Coll Cardiol. 2005;45(2):285–92.

    PubMed  Article  Google Scholar 

  209. 209.

    Kapa S, et al. Contact electroanatomic mapping derived voltage criteria for characterizing left atrial scar in patients undergoing ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2014;25(10):1044–52.

    PubMed  Article  Google Scholar 

  210. 210.

    Oakes RS, et al. Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. Circulation. 2009;119(13):1758–67.

    PubMed  PubMed Central  Article  Google Scholar 

  211. 211.

    McGann C, et al. Atrial fibrillation ablation outcome is predicted by left atrial remodeling on MRI. Circ Arrhythm Electrophysiol. 2014;7(1):23–30.

    PubMed  Article  Google Scholar 

  212. 212.

    Dagres N, et al. Current ablation techniques for persistent atrial fibrillation: results of the European heart rhythm association survey. Europace. 2015;17(10):1596–600.

    PubMed  Article  Google Scholar 

  213. 213.

    Nademanee K, et al. Clinical outcomes of catheter substrate ablation for high-risk patients with atrial fibrillation. J Am Coll Cardiol. 2008;51(8):843–9.

    PubMed  Article  Google Scholar 

  214. 214.

    Haissaguerre M, et al. Localized sources maintaining atrial fibrillation organized by prior ablation. Circulation. 2006;113(5):616–25.

    PubMed  Article  Google Scholar 

  215. 215.

    Haissaguerre M, et al. Catheter ablation of long-lasting persistent atrial fibrillation: critical structures for termination. J Cardiovasc Electrophysiol. 2005;16(11):1125–37.

    PubMed  Article  Google Scholar 

  216. 216.

    Takahashi Y, et al. Characterization of electrograms associated with termination of chronic atrial fibrillation by catheter ablation. J Am Coll Cardiol. 2008;51(10):1003–10.

    PubMed  Article  Google Scholar 

  217. 217.

    Singh SM, et al. Intraprocedural use of ibutilide to organize and guide ablation of complex fractionated atrial electrograms: preliminary assessment of a modified step-wise approach to ablation of persistent atrial fibrillation. J Cardiovasc Electrophysiol. 2010;21(6):608–16.

    PubMed  Article  Google Scholar 

  218. 218.

    Narayan SM, et al. Classifying fractionated electrograms in human atrial fibrillation using monophasic action potentials and activation mapping: evidence for localized drivers, rate acceleration, and nonlocal signal etiologies. Heart Rhythm. 2011;8(2):244–53.

    PubMed  Article  Google Scholar 

  219. 219.

    Verma A, et al. Selective CFAE targeting for atrial fibrillation study (SELECT AF): clinical rationale, design, and implementation. J Cardiovasc Electrophysiol. 2011;22(5):541–7.

    PubMed  Article  Google Scholar 

  220. 220.

    Quintanilla JG, et al. Mechanistic approaches to detect, target, and ablate the drivers of atrial fibrillation. Circ Arrhythm Electrophysiol. 2016;9(1):e002481.

    PubMed  PubMed Central  Article  Google Scholar 

  221. 221.

    Hansen BJ, et al. Atrial fibrillation driven by micro-anatomic intramural re-entry revealed by simultaneous sub-epicardial and sub-endocardial optical mapping in explanted human hearts. Eur Heart J. 2015;36(35):2390–401.

    PubMed  PubMed Central  Article  Google Scholar 

  222. 222.

    Cuculich PS, et al. Noninvasive characterization of epicardial activation in humans with diverse atrial fibrillation patterns. Circulation. 2010;122(S):1364–72.

    PubMed  PubMed Central  Article  Google Scholar 

  223. 223.

    Haissaguerre M, et al. Driver domains in persistent atrial fibrillation. Circulation. 2014;130(7):530–8.

    PubMed  Article  Google Scholar 

  224. 224.

    Narayan SM, et al. Ablation of rotor and focal sources reduces late recurrence of atrial fibrillation compared with trigger ablation alone: extended follow-up of the CONFIRM trial (conventional ablation for atrial fibrillation with or without focal impulse and rotor modulation). J Am Coll Cardiol. 2014;63(17):1761–8.

    PubMed  PubMed Central  Article  Google Scholar 

  225. 225.

    Lin YJ, et al. Prevalence, characteristics, mapping, and catheter ablation of potential rotors in nonparoxysmal atrial fibrillation. Circ Arrhythm Electrophysiol. 2013;6(5):851–8.

    PubMed  Article  Google Scholar 

  226. 226.

    Lin Y-J, et al. Benefits of atrial substrate modification guided by electrogram similarity and phase mapping techniques to eliminate rotors and focal sources versus conventional defragmentation in persistent atrial fibrillation. JACC: Clinical Electrophysiology. 2016;2(6):667–78.

    Google Scholar 

  227. 227.

    Miller JM, et al. Initial independent outcomes from focal impulse and rotor modulation ablation for atrial fibrillation: multicenter FIRM registry. J Cardiovasc Electrophysiol. 2014;25(9):921–9.

    PubMed  PubMed Central  Article  Google Scholar 

  228. 228.

    Lin YJ, et al. Electrophysiological characteristics and catheter ablation in patients with paroxysmal right atrial fibrillation. Circulation. 2005;112(12):1692–700.

    PubMed  Article  Google Scholar 

  229. 229.

    Narayan SM, et al. Treatment of atrial fibrillation by the ablation of localized sources: CONFIRM (conventional ablation for atrial fibrillation with or without focal impulse and rotor modulation) trial. J Am Coll Cardiol. 2012;60(7):628–36.

    PubMed  PubMed Central  Article  Google Scholar 

  230. 230.

    Rappel WJ, Narayan SM. Theoretical considerations for mapping activation in human cardiac fibrillation. Chaos. 2013;23(2):023113.

    PubMed  PubMed Central  Article  Google Scholar 

  231. 231.

    Gianni C, et al. Acute and early outcomes of focal impulse and rotor modulation (FIRM)-guided rotors-only ablation in patients with nonparoxysmal atrial fibrillation. Heart Rhythm. 2016;13(4):830–5.

    PubMed  Article  Google Scholar 

  232. 232.

    Narayan SM, Zaman JA. Mechanistically based mapping of human cardiac fibrillation. J Physiol. 2016;594(9):2399–415.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  233. 233.

    Sommer P, et al. Successful repeat catheter ablation of recurrent long-standing persistent atrial fibrillation with rotor elimination as the procedural endpoint: a case series. J Cardiovasc Electrophysiol. 2016;27(3):274–80.

    PubMed  Article  Google Scholar 

  234. 234.

    Buch E, et al. Long-term clinical outcomes of focal impulse and rotor modulation for treatment of atrial fibrillation: a multicenter experience. Heart Rhythm. 2016;13(3):636–41.

    PubMed  Article  Google Scholar 

  235. 235.

    Benharash P, et al. Quantitative analysis of localized sources identified by focal impulse and rotor modulation mapping in atrial fibrillation. Circ Arrhythm Electrophysiol. 2015;8(3):554–61.

    PubMed  PubMed Central  Article  Google Scholar 

  236. 236.

    Ramanathan C, et al. Noninvasive electrocardiographic imaging for cardiac electrophysiology and arrhythmia. Nat Med. 2004;10(4):422–8.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  237. 237.

    Lim HS, et al. Noninvasive mapping to guide atrial fibrillation ablation. Card Electrophysiol Clin. 2015;7(1):89–98.

    PubMed  Article  Google Scholar 

  238. 238.

    Yamashita S, et al. Body surface mapping to guide atrial fibrillation ablation. Arrhythmia Electrophysiol Rev. 2015;4(3):172–6.

    Article  Google Scholar 

  239. 239.

    Guillem MS, et al. Noninvasive mapping of human atrial fibrillation. J Cardiovasc Electrophysiol. 2009;20(5):507–13.

    PubMed  Article  Google Scholar 

  240. 240.

    Guillem MS, et al. Noninvasive localization of maximal frequency sites of atrial fibrillation by body surface potential mapping. Circ Arrhythm Electrophysiol. 2013;6(2):294–301.

    PubMed  PubMed Central  Article  Google Scholar 

  241. 241.

    Rodrigo M, et al. Body surface localization of left and right atrial high-frequency rotors in atrial fibrillation patients: a clinical-computational study. Heart Rhythm. 2014;11(9):1584–91.

    PubMed  PubMed Central  Article  Google Scholar 

  242. 242.

    Armour JA, et al. Gross and microscopic anatomy of the human intrinsic cardiac nervous system. Anat Rec. 1997;247(2):289–98.

    CAS  PubMed  Article  Google Scholar 

  243. 243.

    Po SS, Nakagawa H, Jackman WM. Localization of left atrial ganglionated plexi in patients with atrial fibrillation. J Cardiovasc Electrophysiol. 2009;20(10):1186–9.

    PubMed  Article  Google Scholar 

  244. 244.

    Patterson E, et al. Triggered firing in pulmonary veins initiated by in vitro autonomic nerve stimulation. Heart Rhythm. 2005;2(6):624–31.

    PubMed  Article  Google Scholar 

  245. 245.

    Choi EK, et al. Intrinsic cardiac nerve activity and paroxysmal atrial tachyarrhythmia in ambulatory dogs. Circulation. 2010;121(24):2615–23.

    PubMed  PubMed Central  Article  Google Scholar 

  246. 246.

    Katritsis DG, et al. Autonomic denervation added to pulmonary vein isolation for paroxysmal atrial fibrillation: a randomized clinical trial. J Am Coll Cardiol. 2013;62(24):2318–25.

    PubMed  Article  Google Scholar 

  247. 247.

    Nakagawa H, et al. Pathophysiologic basis of autonomic ganglionated plexus ablation in patients with atrial fibrillation. Heart Rhythm. 2009;6(12 Suppl):S26–34.

    PubMed  Article  Google Scholar 

  248. 248.

    Bettoni M, Zimmermann M. Autonomic tone variations before the onset of paroxysmal atrial fibrillation. Circulation. 2002;105(23):2753–9.

    PubMed  Article  Google Scholar 

  249. 249.

    Pauza DH, et al. Morphology, distribution, and variability of the epicardiac neural ganglionated subplexuses in the human heart. Anat Rec. 2000;259(4):353–82.

    CAS  PubMed  Article  Google Scholar 

  250. 250.

    Scherlag BJ, et al. Electrical stimulation to identify neural elements on the heart: their role in atrial fibrillation. J Interv Card Electrophysiol. 2005;13(Suppl 1):37–42.

    PubMed  Article  Google Scholar 

  251. 251.

    Patterson E, et al. Sodium-calcium exchange initiated by the Ca2+ transient: an arrhythmia trigger within pulmonary veins. J Am Coll Cardiol. 2006;47(6):1196–206.

    CAS  PubMed  Article  Google Scholar 

  252. 252.

    Lemola K, et al. Pulmonary vein region ablation in experimental vagal atrial fibrillation: role of pulmonary veins versus autonomic ganglia. Circulation. 2008;117(4):470–7.

    PubMed  Article  Google Scholar 

  253. 253.

    Nishida K, et al. The role of pulmonary veins vs. autonomic ganglia in different experimental substrates of canine atrial fibrillation. Cardiovasc Res. 2011;89(4):825–33.

    CAS  PubMed  Article  Google Scholar 

  254. 254.

    Nishida K, et al. Atrial fibrillation ablation: translating basic mechanistic insights to the patient. J Am Coll Cardiol. 2014;64:823–31.

    PubMed  Article  Google Scholar 

  255. 255.

    Stavrakis S, et al. The role of the autonomic ganglia in atrial fibrillation. JACC Clin Electrophysiol. 2015;1(1-2):1–13.

    PubMed  PubMed Central  Article  Google Scholar 

  256. 256.

    Pokushalov E, et al. Left atrial ablation at the anatomic areas of ganglionated plexi for paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 2010;33(10):1231–8.

    PubMed  Article  Google Scholar 

  257. 257.

    Pokushalov E, et al. Ganglionated plexi ablation for long-standing persistent atrial fibrillation. Europace. 2010;12(3):342–6.

    PubMed  Article  Google Scholar 

  258. 258.

    Pokushalov E, et al. Catheter versus surgical ablation of atrial fibrillation after a failed initial pulmonary vein isolation procedure: a randomized controlled trial. J Cardiovasc Electrophysiol. 2013;24(12):1338–43.

    PubMed  Article  Google Scholar 

  259. 259.

    Pokushalov E, et al. Ganglionated plexus ablation vs linear ablation in patients undergoing pulmonary vein isolation for persistent/long-standing persistent atrial fibrillation: a randomized comparison. Heart Rhythm. 2013;10(9):1280–6.

    PubMed  Article  Google Scholar 

  260. 260.

    Lloyd-Jones DM, et al. Lifetime risk for development of atrial fibrillation: the Framingham heart study. Circulation. 2004;110(9):1042–6.

    PubMed  Article  Google Scholar 

  261. 261.

    Mahajan R, et al. Electrophysiological, electroanatomical, and structural remodeling of the atria as consequences of sustained obesity. J Am Coll Cardiol. 2015;66(1):1–11.

    CAS  PubMed  Article  Google Scholar 

  262. 262.

    Wokhlu A, et al. Long-term outcome of atrial fibrillation ablation: impact and predictors of very late recurrence. J Cardiovasc Electrophysiol. 2010;21(10):1071–8.

    PubMed  Article  Google Scholar 

  263. 263.

    Dublin S, et al. Risk of new-onset atrial fibrillation in relation to body mass index. Arch Intern Med. 2006;166(21):2322–8.

    PubMed  Article  Google Scholar 

  264. 264.

    Gami AS, et al. Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation. J Am Coll Cardiol. 2007;49(5):565–71.

    PubMed  Article  Google Scholar 

  265. 265.

    Tedrow UB, et al. The long- and short-term impact of elevated body mass index on the risk of new atrial fibrillation the WHS (Women's health study). J Am Coll Cardiol. 2010;55(21):2319–27.

    PubMed  PubMed Central  Article  Google Scholar 

  266. 266.

    Huxley RR, et al. Absolute and attributable risks of atrial fibrillation in relation to optimal and borderline risk factors: the atherosclerosis risk in communities (ARIC) study. Circulation. 2011;123(14):1501–8.

    PubMed  PubMed Central  Article  Google Scholar 

  267. 267.

    Munger TM, et al. Electrophysiological and hemodynamic characteristics associated with obesity in patients with atrial fibrillation. J Am Coll Cardiol. 2012;60(9):851–60.

    PubMed  Article  Google Scholar 

  268. 268.

    Abed HS, et al. Obesity results in progressive atrial structural and electrical remodeling: implications for atrial fibrillation. Heart Rhythm. 2013;10(1):90–100.

    PubMed  Article  Google Scholar 

  269. 269.

    Richter B, et al. Is inducibility of atrial fibrillation after radio frequency ablation really a relevant prognostic factor? Eur Heart J. 2006;27(21):2553–9.

    PubMed  Article  Google Scholar 

  270. 270.

    Jongnarangsin K, et al. Body mass index, obstructive sleep apnea, and outcomes of catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2008;19(7):668–72.

    PubMed  Article  Google Scholar 

  271. 271.

    Shah AN, et al. Long-term outcome following successful pulmonary vein isolation: pattern and prediction of very late recurrence. J Cardiovasc Electrophysiol. 2008;19(7):661–7.

    PubMed  Article  Google Scholar 

  272. 272.

    Chang SL, et al. Comparison of outcome in catheter ablation of atrial fibrillation in patients with versus without the metabolic syndrome. Am J Cardiol. 2009;103(1):67–72.

    PubMed  Article  Google Scholar 

  273. 273.

    Letsas KP, et al. Pre-ablative predictors of atrial fibrillation recurrence following pulmonary vein isolation: the potential role of inflammation. Europace. 2009;11(2):158–63.

    PubMed  Article  Google Scholar 

  274. 274.

    Tang RB, et al. Metabolic syndrome and risk of recurrence of atrial fibrillation after catheter ablation. Circ J. 2009;73(3):438–43.

    PubMed  Article  Google Scholar 

  275. 275.

    Jin Hwang H, et al. Atrial electroanatomical remodeling as a determinant of different outcomes between two current ablation strategies: circumferential pulmonary vein isolation vs pulmonary vein isolation. Clin Cardiol. 2010;33(3):E69–74.

    PubMed  Article  Google Scholar 

  276. 276.

    Patel D, et al. Outcomes and complications of catheter ablation for atrial fibrillation in females. Heart Rhythm. 2010;7(2):167–72.

    PubMed  Article  Google Scholar 

  277. 277.

    Patel D, et al. Safety and efficacy of pulmonary vein antral isolation in patients with obstructive sleep apnea: the impact of continuous positive airway pressure. Circ Arrhythm Electrophysiol. 2010;3(5):445–51.

    PubMed  Article  Google Scholar 

  278. 278.

    Patel D, et al. The impact of statins and renin-angiotensin-aldosterone system blockers on pulmonary vein antrum isolation outcomes in post-menopausal females. Europace. 2010;12(3):322–30.

    PubMed  Article  Google Scholar 

  279. 279.

    Chao TF, et al. Associations between renal function, atrial substrate properties and outcome of catheter ablation in patients with paroxysmal atrial fibrillation. Circ J. 2011;75(10):2326–32.

    CAS  PubMed  Article  Google Scholar 

  280. 280.

    Winkle RA, et al. Relation of early termination of persistent atrial fibrillation by cardioversion or drugs to ablation outcomes. Am J Cardiol. 2011;108(3):374–9.

    PubMed  Article  Google Scholar 

  281. 281.

    Wong CX, et al. Pericardial fat is associated with atrial fibrillation severity and ablation outcome. J Am Coll Cardiol. 2011;57(17):1745–51.

    PubMed  Article  Google Scholar 

  282. 282.

    Kang JH, et al. Prediction of long-term outcomes of catheter ablation of persistent atrial fibrillation by parameters of preablation DC cardioversion. J Cardiovasc Electrophysiol. 2012;23(11):1165–70.

    PubMed  Article  Google Scholar 

  283. 283.

    Mohanty S, et al. Impact of metabolic syndrome on procedural outcomes in patients with atrial fibrillation undergoing catheter ablation. J Am Coll Cardiol. 2012;59(14):1295–301.

    PubMed  Article  Google Scholar 

  284. 284.

    Ejima K, et al. Impact of diastolic dysfunction on the outcome of catheter ablation in patients with atrial fibrillation. Int J Cardiol. 2013;164(1):88–93.

    PubMed  Article  Google Scholar 

  285. 285.

    Letsas KP, et al. The impact of body mass index on the efficacy and safety of catheter ablation of atrial fibrillation. Int J Cardiol. 2013;164(1):94–8.

    PubMed  Article  Google Scholar 

  286. 286.

    Wong CX, et al. Obesity and the risk of incident, post-operative, and post-ablation atrial fibrillation: a meta-analysis of 626,603 individuals in 51 studies. JACC: Clinical Electrophysiology. 2015;1(3):139–52.

    Google Scholar 

  287. 287.

    Alonso A, et al. Effect of an intensive lifestyle intervention on atrial fibrillation risk in individuals with type 2 diabetes: the Look AHEAD randomized trial. Am Heart J. 2015;170(4):770–777.e5.

    PubMed  PubMed Central  Article  Google Scholar 

  288. 288.

    Pathak RK, et al. Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study. J Am Coll Cardiol. 2014;64(21):2222–31.

    PubMed  Article  Google Scholar 

  289. 289.

    Bitter T, et al. Sleep-disordered breathing and cardiac arrhythmias. Can J Cardiol. 2015;31(7):928–34.

    PubMed  Article  Google Scholar 

  290. 290.

    Fletcher EC. Effect of episodic hypoxia on sympathetic activity and blood pressure. Respir Physiol. 2000;119(2-3):189–97.

    CAS  PubMed  Article  Google Scholar 

  291. 291.

    Kraiczi H, et al. Increased vasoconstrictor sensitivity in obstructive sleep apnea. J Appl Physiol. 1985;89(2):493–8.

    Google Scholar 

  292. 292.

    Ghias M, et al. The role of ganglionated plexi in apnea-related atrial fibrillation. J Am Coll Cardiol. 2009;54(22):2075–83.

    PubMed  Article  Google Scholar 

  293. 293.

    Linz D, et al. Negative tracheal pressure during obstructive respiratory events promotes atrial fibrillation by vagal activation. Heart Rhythm. 2011;8(9):1436–43.

    PubMed  Article  Google Scholar 

  294. 294.

    Linz D, et al. Renal sympathetic denervation suppresses postapneic blood pressure rises and atrial fibrillation in a model for sleep apnea. Hypertension. 2012;60(1):172–8.

    CAS  PubMed  Article  Google Scholar 

  295. 295.

    Linz D, et al. Effect of renal denervation on neurohumoral activation triggering atrial fibrillation in obstructive sleep apnea. Hypertension. 2013;62(4):767–74.

    CAS  PubMed  Article  Google Scholar 

  296. 296.

    Iwasaki YK, et al. Determinants of atrial fibrillation in an animal model of obesity and acute obstructive sleep apnea. Heart Rhythm. 2012;9(9):1409–1416.e1.

    PubMed  Article  Google Scholar 

  297. 297.

    Iwasaki YK, et al. Atrial fibrillation promotion with long-term repetitive obstructive sleep apnea in a rat model. J Am Coll Cardiol. 2014;64(19):2013–23.

    PubMed  Article  Google Scholar 

  298. 298.

    Dimitri H, et al. Atrial remodeling in obstructive sleep apnea: implications for atrial fibrillation. Heart Rhythm. 2012;9(3):321–7.

    PubMed  Article  Google Scholar 

  299. 299.

    Stevenson IH, et al. Atrial electrophysiology is altered by acute hypercapnia but not hypoxemia: implications for promotion of atrial fibrillation in pulmonary disease and sleep apnea. Heart Rhythm. 2010;7(9):1263–70.

    PubMed  Article  Google Scholar 

  300. 300.

    Holmqvist F, et al. Impact of obstructive sleep apnea and continuous positive airway pressure therapy on outcomes in patients with atrial fibrillation-results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Am Heart J. 2015;169(5):647–654.e2.

    PubMed  Article  Google Scholar 

  301. 301.

    Kwon Y, et al. Association of sleep characteristics with atrial fibrillation: the multi-ethnic study of atherosclerosis. Thorax. 2015;70(9):873–9.

    PubMed  PubMed Central  Article  Google Scholar 

  302. 302.

    Kanagala R, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20):2589–94.

    PubMed  Google Scholar 

  303. 303.

    Fein AS, et al. Treatment of obstructive sleep apnea reduces the risk of atrial fibrillation recurrence after catheter ablation. J Am Coll Cardiol. 2013;62(4):300–5.

    PubMed  Article  Google Scholar 

  304. 304.

    Matiello M, et al. Low efficacy of atrial fibrillation ablation in severe obstructive sleep apnoea patients. Europace. 2010;12(8):1084–9.

    PubMed  Article  Google Scholar 

  305. 305.

    Naruse Y, et al. Concomitant obstructive sleep apnea increases the recurrence of atrial fibrillation following radiofrequency catheter ablation of atrial fibrillation: clinical impact of continuous positive airway pressure therapy. Heart Rhythm. 2013;10(3):331–7.

    PubMed  Article  Google Scholar 

  306. 306.

    Neilan TG, et al. Effect of sleep apnea and continuous positive airway pressure on cardiac structure and recurrence of atrial fibrillation. J Am Heart Assoc. 2013;2(6):e000421.

    PubMed  PubMed Central  Article  Google Scholar 

  307. 307.

    Li L, et al. Efficacy of catheter ablation of atrial fibrillation in patients with obstructive sleep apnoea with and without continuous positive airway pressure treatment: a meta-analysis of observational studies. Europace. 2014;16(9):1309–14.

    PubMed  Article  Google Scholar 

  308. 308.

    Raitt MH, et al. Reversal of electrical remodeling after cardioversion of persistent atrial fibrillation. J Cardiovasc Electrophysiol. 2004;15(5):507–12.

    PubMed  Article  Google Scholar 

  309. 309.

    Chalfoun N, et al. Reverse electrical remodeling of the atria post cardioversion in patients who remain in sinus rhythm assessed by signal averaging of the P-wave. Pacing Clin Electrophysiol. 2007;30(4):502–9.

    PubMed  Article  Google Scholar 

  310. 310.

    Igarashi M, et al. Effect of restoration of sinus rhythm by extensive antiarrhythmic drugs in predicting results of catheter ablation of persistent atrial fibrillation. Am J Cardiol. 2010;106(1):62–8.

    CAS  PubMed  Article  Google Scholar 

  311. 311.

    Rivard L, et al. Improved outcome following restoration of sinus rhythm prior to catheter ablation of persistent atrial fibrillation: a comparative multicenter study. Heart Rhythm. 2012;9(7):1025–30.

    PubMed  Article  Google Scholar 

  312. 312.

    Mohanty S, et al. Effect of periprocedural amiodarone on procedure outcome in patients with long-standing persistent atrial fibrillation undergoing extended pulmonary vein antrum isolation: results from a randomized study (SPECULATE). Heart Rhythm. 2015;12(3):477–83.

    PubMed  Article  Google Scholar 

  313. 313.

    Robbins IM, et al. Pulmonary vein stenosis after catheter ablation of atrial fibrillation. Circulation. 1998;98(17):1769–75.

    CAS  PubMed  Article  Google Scholar 

  314. 314.

    Ernst S, et al. Total pulmonary vein occlusion as a consequence of catheter ablation for atrial fibrillation mimicking primary lung disease. J Cardiovasc Electrophysiol. 2003;14(4):366–70.

    PubMed  Article  Google Scholar 

  315. 315.

    Mansour M, et al. Assessment of pulmonary vein anatomic variability by magnetic resonance imaging: implications for catheter ablation techniques for atrial fibrillation. J Cardiovasc Electrophysiol. 2004;15(4):387–93.

    PubMed  Article  Google Scholar 

  316. 316.

    Holmes DR Jr, Monahan KH, Packer D. Pulmonary vein stenosis complicating ablation for atrial fibrillation: clinical spectrum and interventional considerations. JACC Cardiovasc Interv. 2009;2(4):267–76.

    PubMed  Article  Google Scholar 

  317. 317.

    Fender EA, Packer DL, Holmes Jr. DR. Pulmonary vein stenosis after atrial fibrillation ablation. EuroIntervention. 2016;12(Suppl X):X31–4.

    PubMed  Article  Google Scholar 

  318. 318.

    Di Biase L, et al. Pulmonary vein total occlusion following catheter ablation for atrial fibrillation: clinical implications after long-term follow-up. J Am Coll Cardiol. 2006;48(12):2493–9.

    PubMed  Article  Google Scholar 

  319. 319.

    Prieto LR, et al. Comparison of stent versus balloon angioplasty for pulmonary vein stenosis complicating pulmonary vein isolation. J Cardiovasc Electrophysiol. 2008;19(7):673–8.

    PubMed  Article  Google Scholar 

  320. 320.

    Packer DL, et al. Clinical presentation, investigation, and management of pulmonary vein stenosis complicating ablation for atrial fibrillation. Circulation. 2005;111(5):546–54.

    PubMed  Article  Google Scholar 

  321. 321.

    Taylor GW, et al. Pathological effects of extensive radiofrequency energy applications in the pulmonary veins in dogs. Circulation. 2000;101(14):1736–42.

    CAS  PubMed  Article  Google Scholar 

  322. 322.

    Arentz T, et al. Incidence of pulmonary vein stenosis 2 years after radiofrequency catheter ablation of refractory atrial fibrillation. Eur Heart J. 2003;24(10):963–9.

    PubMed  Article  Google Scholar 

  323. 323.

    Tse HF, et al. Pulmonary vein isolation using transvenous catheter cryoablation for treatment of atrial fibrillation without risk of pulmonary vein stenosis. J Am Coll Cardiol. 2003;42(4):752–8.

    PubMed  Article  Google Scholar 

  324. 324.

    Kasper L, et al. Hemoptysis and lung disease as a manifestation of pulmonary vein stenosis after cryoballoon catheter ablation for atrial fibrillation. Pol Arch Med Wewn. 2016;126(1-2):94–6.

    PubMed  Google Scholar 

  325. 325.

    Dong J, et al. Incidence and predictors of pulmonary vein stenosis following catheter ablation of atrial fibrillation using the anatomic pulmonary vein ablation approach: results from paired magnetic resonance imaging. J Cardiovasc Electrophysiol. 2005;16(8):845–52.

    PubMed  Article  Google Scholar 

  326. 326.

    Hoyt RH, et al. Transvenous catheter cryoablation for treatment of atrial fibrillation: results of a feasibility study. Pacing Clin Electrophysiol. 2005;28(Suppl 1):S78–82.

    PubMed  Article  Google Scholar 

  327. 327.

    Saad EB, et al. Pulmonary vein stenosis after catheter ablation of atrial fibrillation: emergence of a new clinical syndrome. Ann Intern Med. 2003;138(8):634–8.

    PubMed  Article  Google Scholar 

  328. 328.

    Hilbert S, et al. Pulmonary vein collateral formation as a long-term result of post-interventional pulmonary vein stenosis. Eur Heart J. 2016;37(31):2474.

    PubMed  Article  Google Scholar 

  329. 329.

    Hilbert S, Sommer P, Bollmann A. Pulmonary vein dilatation in a case of total pulmonary vein occlusion: contemporary approach using a combination of 3D-mapping system and image integration. Catheter Cardiovasc Interv. 2016;88(7):E227–32.

    PubMed  Article  Google Scholar 

  330. 330.

    Fender EA, et al. Severe pulmonary vein stenosis resulting from ablation for atrial fibrillation: presentation, management, and clinical outcomes. Circulation. 2016;134(23):1812–21.

    CAS  PubMed  Article  Google Scholar 

  331. 331.

    De Potter TJ, et al. Drug-eluting stents for the treatment of pulmonary vein stenosis after atrial fibrillation ablation. Europace. 2011;13(1):57–61.

    PubMed  Article  Google Scholar 

  332. 332.

    Kanter KR, Kirshbom PM, Kogon BE. Surgical repair of pulmonary venous stenosis: a word of caution. Ann Thorac Surg. 2014;98(5):1687–91. discussion 1691–1692

    PubMed  Article  Google Scholar 

  333. 333.

    Patel NS, et al. Successful surgical repair of iatrogenic pulmonary vein stenosis. J Cardiovasc Electrophysiol. 2012;23(6):656–8.

    PubMed  Article  Google Scholar 

  334. 334.

    Bharat A, et al. Lung transplant is a viable treatment option for patients with congenital and acquired pulmonary vein stenosis. J Heart Lung Transplant. 2013;32(6):621–5.

    PubMed  Article  Google Scholar 

  335. 335.

    Ponamgi SP, et al. Catheter-based intervention for pulmonary vein stenosis due to fibrosing mediastinitis: the Mayo Clinic experience. Int J Cardiol Heart Vasc. 2015;8:103–7.

    PubMed  PubMed Central  Google Scholar 

  336. 336.

    Mohanty S, et al. Impact of alcohol intake on thromboembolic events following catheter ablation for atrial fibrillation. J Am Coll Cardiol. 2014;63(12_S).

  337. 337.

    Di Biase L, et al. Esophageal capsule endoscopy after radiofrequency catheter ablation for atrial fibrillation: documented higher risk of luminal esophageal damage with general anesthesia as compared with conscious sedation. Circ Arrhythm Electrophysiol. 2009;2(2):108–12.

    PubMed  Article  Google Scholar 

  338. 338.

    Cappato R, et al. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. 2005;111(9):1100–5.

    PubMed  Article  Google Scholar 

  339. 339.

    Pappone C, et al. Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation. 2004;109(22):2724–6.

    PubMed  Article  Google Scholar 

  340. 340.

    Martinek M, et al. Identification of a high-risk population for esophageal injury during radiofrequency catheter ablation of atrial fibrillation: procedural and anatomical considerations. Heart Rhythm. 2010;7(9):1224–30.

    PubMed  Article  Google Scholar 

  341. 341.

    Singh SM, et al. Clinical outcomes after repair of left atrial esophageal fistulas occurring after atrial fibrillation ablation procedures. Heart Rhythm. 2013;10(11):1591–7.

    PubMed  Article  Google Scholar 

  342. 342.

    Bunch TJ, et al. Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol. 2006;17(4):435–9.

    PubMed  Article  Google Scholar 

  343. 343.

    Cappato R, et al. Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. J Am Coll Cardiol. 2009;53(19):1798–803.

    PubMed  Article  Google Scholar 

  344. 344.

    Tan C, Coffey A. Atrioesophageal fistula after surgical unipolar radiofrequency atrial ablation for atrial fibrillation. Ann Thorac Surg. 2013;95(3):e61–2.

    PubMed  Article  Google Scholar 

  345. 345.

    Mohanty S. Outcomes of atrio-esophageal fistula following catheter ablation of atrial fibrillation treated with surgical repair versus esophageal stenting. J Cardiovasc Electrophysiol. 2014;25(9):E6.

    PubMed  Article  Google Scholar 

  346. 346.

    Mohanty S, et al. Outcomes of atrioesophageal fistula following catheter ablation of atrial fibrillation treated with surgical repair versus esophageal stenting. J Cardiovasc Electrophysiol. 2014;25(6):579–84.

    PubMed  Article  Google Scholar 

  347. 347.

    Cappato R, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3(1):32–8.

    PubMed  Article  Google Scholar 

  348. 348.

    Gillinov AM, Pettersson G, Rice TW. Esophageal injury during radiofrequency ablation for atrial fibrillation. J Thorac Cardiovasc Surg. 2001;122(6):1239–40.

    CAS  PubMed  Article  Google Scholar 

  349. 349.

    Mohr FW, et al. Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: short-term and midterm results. J Thorac Cardiovasc Surg. 2002;123(5):919–27.

    PubMed  Article  Google Scholar 

  350. 350.

    Doll N, et al. Esophageal perforation during left atrial radiofrequency ablation: is the risk too high? J Thorac Cardiovasc Surg. 2003;125(4):836–42.

    PubMed  Article  Google Scholar 

  351. 351.

    Sonmez B, et al. A fatal complication due to radiofrequency ablation for atrial fibrillation: atrio-esophageal fistula. Ann Thorac Surg. 2003;76(1):281–3.

    PubMed  Article  Google Scholar 

  352. 352.

    Scanavacca MI, et al. Left atrial-esophageal fistula following radiofrequency catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2004;15(8):960–2.

    PubMed  Article  Google Scholar 

  353. 353.

    Borchert B, et al. Lethal atrioesophageal fistula after pulmonary vein isolation using high-intensity focused ultrasound (HIFU). Heart Rhythm. 2008;5(1):145–8.

    PubMed  Article  Google Scholar 

  354. 354.

    Ghia KK, et al. A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation. J Interv Card Electrophysiol. 2009;24(1):33–6.

    PubMed  Article  Google Scholar 

  355. 355.

    Gilcrease GW, Stein JB. A delayed case of fatal atrioesophageal fistula following radiofrequency ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2010;21(6):708–11.

    PubMed  Article  Google Scholar 

  356. 356.

    Stockigt F, et al. Atrioesophageal fistula after cryoballoon pulmonary vein isolation. J Cardiovasc Electrophysiol. 2012;23(11):1254–7.

    PubMed  Article  Google Scholar 

  357. 357.

    Yousuf O, Calkins H. Sounding the warning on the potential for oesophageal injury resulting from use of the nMARQ for ablation of atrial fibrillation. Europace. 2015;17(3):343–4.

    PubMed  Article  Google Scholar 

  358. 358.

    Jackson PG, et al. The vagus plays a role in the anti-reflux barrier by controlling both the lower esophageal sphincter pressure and crural diaphragm activity. J Am Coll Surg. 2005;201(3 Suppl):S11.

    Article  Google Scholar 

  359. 359.

    Nolker G, et al. Esophageal acid levels after pulmonary vein isolation for atrial fibrillation. Pacing Clin Electrophysiol. 2009;32(Suppl 1):S228–30.

    PubMed  Article  Google Scholar 

  360. 360.

    Medeiros De Vasconcelos JT, et al. Atrial-oesophageal fistula following percutaneous radiofrequency catheter ablation of atrial fibrillation: the risk still persists. Europace. 2017;19(2):250–8.

    PubMed  Google Scholar 

  361. 361.

    Rillig A, et al. Modified energy settings are mandatory to minimize oesophageal injury using the novel multipolar irrigated radiofrequency ablation catheter for pulmonary vein isolation. Europace. 2015;17(3):396–402.

    PubMed  Article  Google Scholar 

  362. 362.

    Chavez P, et al. Atrioesophageal fistula following ablation procedures for atrial fibrillation: systematic review of case reports. Open Heart. 2015;2(1):e000257.

    PubMed  PubMed Central  Article  Google Scholar 

  363. 363.

    Mateos JC, et al. Simplified method for esophagus protection during radiofrequency catheter ablation of atrial fibrillation–prospective study of 704 cases. Rev Bras Cir Cardiovasc. 2015;30(2):139–47.

    PubMed  PubMed Central  Google Scholar 

  364. 364.

    Shim HB, et al. Successful management of atrio-esophageal fistula after cardiac radiofrequency catheter ablation. Korean J Thorac Cardiovasc Surg. 2013;46(2):142–5.

    PubMed  PubMed Central  Article  Google Scholar 

  365. 365.

    Black-Maier E, et al. Risk of atrioesophageal fistula formation with contact-force sensing catheters. Heart Rhythm. 2017;S1547–5271(17):30452–6.

    Google Scholar 

  366. 366.

    Santangeli P, et al. Ablation of atrial fibrillation under therapeutic warfarin reduces periprocedural complications: evidence from a meta-analysis. Circ Arrhythm Electrophysiol. 2012;5(2):302–11.

    CAS  PubMed  Article  Google Scholar 

  367. 367.

    Di Biase L, et al. Periprocedural stroke and management of major bleeding complications in patients undergoing catheter ablation of atrial fibrillation: the impact of periprocedural therapeutic international normalized ratio. Circulation. 2010;121(23):2550–6.

    PubMed  Article  CAS  Google Scholar 

  368. 368.

    Wazni OM, et al. Atrial fibrillation ablation in patients with therapeutic international normalized ratio: comparison of strategies of anticoagulation management in the periprocedural period. Circulation. 2007;116(22):2531–4.

    PubMed  Article  Google Scholar 

  369. 369.

    Schmidt M, et al. Atrial fibrillation ablation in patients with therapeutic international normalized ratios. Pacing Clin Electrophysiol. 2009;32(8):995–9.

    PubMed  Article  Google Scholar 

  370. 370.

    Hakalahti A, et al. Catheter ablation of atrial fibrillation in patients with therapeutic oral anticoagulation treatment. Europace. 2011;13(5):640–5.

    PubMed  Article  Google Scholar 

  371. 371.

    Di Biase L, et al. Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the role of Coumadin in preventing thromboembolism in atrial fibrillation (AF) patients undergoing catheter ablation (COMPARE) randomized trial. Circulation. 2014;129(25):2638–44.

    PubMed  Article  CAS  Google Scholar 

  372. 372.

    Hohnloser SH, Camm AJ. Safety and efficacy of dabigatran etexilate during catheter ablation of atrial fibrillation: a meta-analysis of the literature. Europace. 2013;15(10):1407–11.

    PubMed  Article  Google Scholar 

  373. 373.

    Calkins H, et al. RE-CIRCUIT study-randomized evaluation of dabigatran etexilate compared to warfarin in pulmonary vein ablation: assessment of an uninterrupted periprocedural anticoagulation strategy. Am J Cardiol. 2015;115(1):154–5.

    PubMed  Article  Google Scholar 

  374. 374.

    Cappato R, et al. Uninterrupted rivaroxaban vs. uninterrupted vitamin K antagonists for catheter ablation in non-valvular atrial fibrillation. Eur Heart J. 2015;36(28):1805–11.

    PubMed  PubMed Central  Article  Google Scholar 

  375. 375.

    Di Biase L, et al. Feasibility and safety of uninterrupted periprocedural apixaban administration in patients undergoing radiofrequency catheter ablation for atrial fibrillation: results from a multicenter study. Heart Rhythm. 2015;12(6):1162–8.

    PubMed  Article  Google Scholar 

  376. 376.

    Bassiouny M, et al. Use of dabigatran for periprocedural anticoagulation in patients undergoing catheter ablation for atrial fibrillation. Circ Arrhythm Electrophysiol. 2013;6(3):460–6.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  377. 377.

    Bin Abdulhak AA, et al. Safety and efficacy of interrupted dabigatran for peri-procedural anticoagulation in catheter ablation of atrial fibrillation: a systematic review and meta-analysis. Europace. 2013;15(10):1412–20.

    PubMed  Article  Google Scholar 

  378. 378.

    Providencia R, et al. Rivaroxaban and dabigatran in patients undergoing catheter ablation of atrial fibrillation. Europace. 2014;16(8):1137–44.

    PubMed  Article  Google Scholar 

  379. 379.

    Winkle RA, et al. Peri-procedural interrupted oral anticoagulation for atrial fibrillation ablation: comparison of aspirin, warfarin, dabigatran, and rivaroxaban. Europace. 2014;16(10):1443–9.

    PubMed  PubMed Central  Article  Google Scholar 

  380. 380.

    Armbruster HL, et al. Safety of novel oral anticoagulants compared with uninterrupted warfarin for catheter ablation of atrial fibrillation. Ann Pharmacother. 2015;49(3):278–84.

    CAS  PubMed  Article  Google Scholar 

  381. 381.

    Ren JF, Marchlinski FE, Callans DJ. Left atrial thrombus associated with ablation for atrial fibrillation: identification with intracardiac echocardiography. J Am Coll Cardiol. 2004;43(10):1861–7.

    PubMed  Article  Google Scholar 

  382. 382.

    Saksena S, et al. A prospective comparison of cardiac imaging using intracardiac echocardiography with transesophageal echocardiography in patients with atrial fibrillation: the intracardiac echocardiography guided cardioversion helps interventional procedures study. Circ Arrhythm Electrophysiol. 2010;3(6):571–7.

    PubMed  Article  Google Scholar 

  383. 383.

    Baran J, et al. Intracardiac echocardiography for detection of thrombus in the left atrial appendage: comparison with transesophageal echocardiography in patients undergoing ablation for atrial fibrillation: the action-ice I study. Circ Arrhythm Electrophysiol. 2013;6(6):1074–81.

    PubMed  Article  Google Scholar 

  384. 384.

    Ren JF, et al. Intracardiac echocardiographic diagnosis of thrombus formation in the left atrial appendage: a complementary role to transesophageal echocardiography. Echocardiography. 2013;30(1):72–80.

    PubMed  Article  Google Scholar 

  385. 385.

    Anter E, et al. Comparison of intracardiac echocardiography and transesophageal echocardiography for imaging of the right and left atrial appendages. Heart Rhythm. 2014;11(11):1890–7.

    PubMed  Article  Google Scholar 

  386. 386.

    Sriram CS, et al. Detection of left atrial thrombus by intracardiac echocardiography in patients undergoing ablation of atrial fibrillation. J Interv Card Electrophysiol. 2015;43(3):227–36.

    PubMed  Article  Google Scholar 

  387. 387.

    Maleki K, et al. Intracardiac ultrasound detection of thrombus on transseptal sheath: incidence, treatment, and prevention. J Cardiovasc Electrophysiol. 2005;16(6):561–5.

    PubMed  Article  Google Scholar 

  388. 388.

    Wazni OM, et al. Embolic events and char formation during pulmonary vein isolation in patients with atrial fibrillation: impact of different anticoagulation regimens and importance of intracardiac echo imaging. J Cardiovasc Electrophysiol. 2005;16(6):576–81.

    PubMed  Article  Google Scholar 

  389. 389.

    Shah D. Filamentous thrombi during left-sided sheath-assisted catheter ablations. Europace. 2010;12(12):1657–8.

    PubMed  Article  Google Scholar 

  390. 390.

    Ren JF, et al. Increased intensity of anticoagulation may reduce risk of thrombus during atrial fibrillation ablation procedures in patients with spontaneous echo contrast. J Cardiovasc Electrophysiol. 2005;16(5):474–7.

    PubMed  Article  Google Scholar 

  391. 391.

    Bruce CJ, et al. Early heparinization decreases the incidence of left atrial thrombi detected by intracardiac echocardiography during radiofrequency ablation for atrial fibrillation. J Interv Card Electrophysiol. 2008;22(3):211–9.

    PubMed  Article  Google Scholar 

  392. 392.

    Asbach S, et al. Early heparin administration reduces risk for left atrial thrombus formation during atrial fibrillation ablation procedures. Cardiol Res Pract. 2011;2011:615087.

    PubMed  PubMed Central  Article  Google Scholar 

  393. 393.

    Briceno DF, et al. Clinical impact of heparin kinetics during catheter ablation of atrial fibrillation: meta-analysis and meta-regression. J Cardiovasc Electrophysiol. 2016;27(6):683–93.

    PubMed  Article  Google Scholar 

  394. 394.

    Chilukuri K, et al. Incidence and outcomes of protamine reactions in patients undergoing catheter ablation of atrial fibrillation. J Interv Card Electrophysiol. 2009;25(3):175–81.

    PubMed  Article  Google Scholar 

  395. 395.

    Thygesen K, et al. Universal definition of myocardial infarction. J Am Coll Cardiol. 2007;50(22):2173–95.

    PubMed  Article  Google Scholar 

  396. 396.

    Helps SC, et al. The effect of gas emboli on rabbit cerebral blood flow. Stroke. 1990;21(1):94–9.

    CAS  PubMed  Article  Google Scholar 

  397. 397.

    Krivonyak GS, Warren SG. Cerebral arterial air embolism treated by a vertical head-down maneuver. Catheter Cardiovasc Interv. 2000;49(2):185–7.

    CAS  PubMed  Article  Google Scholar 

  398. 398.

    Cauchemez B, et al. High-flow perfusion of sheaths for prevention of thromboembolic complications during complex catheter ablation in the LA. J Cardiovasc Electrophysiol. 2004;15(3):276–83.

    PubMed  Article  Google Scholar 

  399. 399.

    Kuwahara T, et al. Clinical characteristics of massive air embolism complicating left atrial ablation of atrial fibrillation: lessons from five cases. Europace. 2012;14(2):204–8.

    PubMed  Article  Google Scholar 

  400. 400.

    Franzen OW, et al. Mechanisms underlying air aspiration in patients undergoing left atrial catheterization. Catheter Cardiovasc Interv. 2008;71(4):553–8.

    PubMed  Article  Google Scholar 

  401. 401.

    Ryu KH, et al. Heparin reduces neurological impairment after cerebral arterial air embolism in the rabbit. Stroke. 1996;27(2):303–9. discussion 310

    CAS  PubMed  Article  Google Scholar 

  402. 402.

    Gaita F, et al. Incidence of silent cerebral thromboembolic lesions after atrial fibrillation ablation may change according to technology used: comparison of irrigated radiofrequency, multipolar nonirrigated catheter and cryoballoon. J Cardiovasc Electrophysiol. 2011;22(9):961–8.

    PubMed  Article  Google Scholar 

  403. 403.

    Herrera Siklody C, et al. Incidence of asymptomatic intracranial embolic events after pulmonary vein isolation: comparison of different atrial fibrillation ablation technologies in a multicenter study. J Am Coll Cardiol. 2011;58(7):681–8.

    PubMed  Article  Google Scholar 

  404. 404.

    Verma A, et al. Evaluation and reduction of asymptomatic cerebral embolism in ablation of atrial fibrillation, but high prevalence of chronic silent infarction: results of the evaluation of reduction of asymptomatic cerebral embolism trial. Circ Arrhythm Electrophysiol. 2013;6(5):835–42.

    PubMed  Article  Google Scholar 

  405. 405.

    De Greef Y, et al. Low rate of asymptomatic cerebral embolism and improved procedural efficiency with the novel pulmonary vein ablation catheter GOLD: results of the PRECISION GOLD trial. Europace. 2016;18(5):687–95.

    PubMed  PubMed Central  Article  Google Scholar 

  406. 406.

    Deneke T, et al. Silent cerebral events/lesions related to atrial fibrillation ablation: a clinical review. J Cardiovasc Electrophysiol. 2015;26(4):455–63.

    PubMed  Article  Google Scholar 

  407. 407.

    Merchant FM, Delurgio DB. Catheter ablation of atrial fibrillation and risk of asymptomatic cerebral embolism. Pacing Clin Electrophysiol. 2014;37(3):389–97.

    PubMed  Article  Google Scholar 

  408. 408.

    Lickfett L, et al. Cerebral diffusion-weighted magnetic resonance imaging: a tool to monitor the thrombogenicity of left atrial catheter ablation. J Cardiovasc Electrophysiol. 2006;17(1):1–7.

    PubMed  Google Scholar 

  409. 409.

    Gaita F, et al. Radiofrequency catheter ablation of atrial fibrillation: a cause of silent thromboembolism? Magnetic resonance imaging assessment of cerebral thromboembolism in patients undergoing ablation of atrial fibrillation. Circulation. 2010;122(17):1667–73.

    PubMed  Article  Google Scholar 

  410. 410.

    Schrickel JW, et al. Incidence and predictors of silent cerebral embolism during pulmonary vein catheter ablation for atrial fibrillation. Europace. 2010;12(1):52–7.

    PubMed  Article  Google Scholar 

  411. 411.

    Deneke T, et al. Postablation asymptomatic cerebral lesions: long-term follow-up using magnetic resonance imaging. Heart Rhythm. 2011;8(11):1705–11.

    PubMed  Article  Google Scholar 

  412. 412.

    Sauren LD, et al. Transcranial measurement of cerebral microembolic signals during endocardial pulmonary vein isolation: comparison of three different ablation techniques. J Cardiovasc Electrophysiol. 2009;20(10):1102–7.

    PubMed  Article  Google Scholar 

  413. 413.

    Wieczorek M, et al. Investigation into causes of abnormal cerebral MRI findings following PVAC duty-cycled, phased RF ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2013;24(2):121–8.

    PubMed  Article  Google Scholar 

  414. 414.

    Bendszus M, Stoll G. Silent cerebral ischaemia: hidden fingerprints of invasive medical procedures. Lancet Neurol. 2006;5(4):364–72.

    PubMed  Article  Google Scholar 

  415. 415.

    Kruis RW, Vlasveld FA, Van Dijk D. The (un)importance of cerebral microemboli. Semin Cardiothorac Vasc Anesth. 2010;14(2):111–8.

    PubMed  Article  Google Scholar 

  416. 416.

    Medi C, et al. Subtle post-procedural cognitive dysfunction after atrial fibrillation ablation. J Am Coll Cardiol. 2013;62(6):531–9.

    PubMed  Article  Google Scholar 

  417. 417.

    Ichiki H, et al. The incidence of asymptomatic cerebral microthromboembolism after atrial fibrillation ablation: comparison of warfarin and dabigatran. Pacing Clin Electrophysiol. 2013;36(11):1328–35.

    PubMed  Article  Google Scholar 

  418. 418.

    Nagy-Balo E, et al. Transcranial measurement of cerebral microembolic signals during pulmonary vein isolation: a comparison of two ablation techniques. Circ Arrhythm Electrophysiol. 2013;6(3):473–80.

    PubMed  Article  Google Scholar 

  419. 419.

    Vermeer SE, et al. Silent brain infarcts and the risk of dementia and cognitive decline. N Engl J Med. 2003;348(13):1215–22.

    PubMed  Article  Google Scholar 

  420. 420.

    Neven K, et al. Fatal end of a safety algorithm for pulmonary vein isolation with use of high-intensity focused ultrasound. Circ Arrhythm Electrophysiol. 2010;3(3):260–5.

    PubMed  Article  Google Scholar 

  421. 421.

    Ripley KL, et al. Time course of esophageal lesions after catheter ablation with cryothermal and radiofrequency ablation: implication for atrio-esophageal fistula formation after catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2007;18(6):642–6.

    PubMed  Article  Google Scholar 

  422. 422.

    Ahmed H, et al. The esophageal effects of cryoenergy during cryoablation for atrial fibrillation. Heart Rhythm. 2009;6(7):962–9.

    PubMed  Article  Google Scholar 

  423. 423.

    Kawasaki R, et al. Atrioesophageal fistula complicating cryoballoon pulmonary vein isolation for paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 2014;25(7):787–92.

    PubMed  Article  Google Scholar 

  424. 424.

    Lim HW, et al. Atrioesophageal fistula during cryoballoon ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2014;25(2):208–13.

    PubMed  Article  Google Scholar 

  425. 425.

    Yokoyama K, et al. Canine model of esophageal injury and atrial-esophageal fistula after applications of forward-firing high-intensity focused ultrasound and side-firing unfocused ultrasound in the left atrium and inside the pulmonary vein. Circ Arrhythm Electrophysiol. 2009;2(1):41–9.

    PubMed  Article  Google Scholar 

  426. 426.

    Singh SM, et al. Esophageal injury and temperature monitoring during atrial fibrillation ablation. Circ Arrhythm Electrophysiol. 2008;1(3):162–8.

    PubMed  Article  Google Scholar 

  427. 427.

    Kuwahara T, et al. Safe and effective ablation of atrial fibrillation: importance of esophageal temperature monitoring to avoid periesophageal nerve injury as a complication of pulmonary vein isolation. J Cardiovasc Electrophysiol. 2009;20(1):1–6.

    PubMed  Article  Google Scholar 

  428. 428.

    Contreras-Valdes FM, et al. Severity of esophageal injury predicts time to healing after radiofrequency catheter ablation for atrial fibrillation. Heart Rhythm. 2011;8(12):1862–8.

    PubMed  Article  Google Scholar 

  429. 429.

    Leite LR, et al. Luminal esophageal temperature monitoring with a deflectable esophageal temperature probe and intracardiac echocardiography may reduce esophageal injury during atrial fibrillation ablation procedures: results of a pilot study. Circ Arrhythm Electrophysiol. 2011;4(2):149–56.

    PubMed  Article  Google Scholar 

  430. 430.

    Tschabrunn CM, et al. Comparison between single- and multi-sensor oesophageal temperature probes during atrial fibrillation ablation: thermodynamic characteristics. Europace. 2015;17(6):891–7.

    PubMed  Article  Google Scholar 

  431. 431.

    Deneke T, et al. Utility of esophageal temperature monitoring during pulmonary vein isolation for atrial fibrillation using duty-cycled phased radiofrequency ablation. J Cardiovasc Electrophysiol. 2011;22(3):255–61.

    PubMed  Article  Google Scholar 

  432. 432.

    Carroll BJ, et al. Multi-sensor esophageal temperature probe used during radiofrequency ablation for atrial fibrillation is associated with increased intraluminal temperature detection and increased risk of esophageal injury compared to single-sensor probe. J Cardiovasc Electrophysiol. 2013;24(9):958–64.

    PubMed  Article  Google Scholar 

  433. 433.

    Muller P, et al. Higher incidence of esophageal lesions after ablation of atrial fibrillation related to the use of esophageal temperature probes. Heart Rhythm. 2015;12(7):1464–9.

    PubMed  Article  Google Scholar 

  434. 434.

    Tsuchiya T, et al. Atrial fibrillation ablation with esophageal cooling with a cooled water-irrigated intraesophageal balloon: a pilot study. J Cardiovasc Electrophysiol. 2007;18(2):145–50.

    PubMed  Article  Google Scholar 

  435. 435.

    Arruda MS, et al. Feasibility and safety of using an esophageal protective system to eliminate esophageal thermal injury: implications on atrial-esophageal fistula following AF ablation. J Cardiovasc Electrophysiol. 2009;20(11):1272–8.

    PubMed  Article  Google Scholar 

  436. 436.

    Kuwahara T, et al. Oesophageal cooling with ice water does not reduce the incidence of oesophageal lesions complicating catheter ablation of atrial fibrillation: randomized controlled study. Europace. 2014;16(6):834–9.

    PubMed  Article  Google Scholar 

  437. 437.

    Kuwahara T, et al. Incidences of esophageal injury during esophageal temperature monitoring: a comparative study of a multi-thermocouple temperature probe and a deflectable temperature probe in atrial fibrillation ablation. J Interv Card Electrophysiol. 2014;39(3):251–7.

    PubMed  Article  Google Scholar 

  438. 438.

    Chugh A, et al. Mechanical displacement of the esophagus in patients undergoing left atrial ablation of atrial fibrillation. Heart Rhythm. 2009;6(3):319–22.

    PubMed  Article  Google Scholar 

  439. 439.

    Koruth JS, et al. Mechanical esophageal displacement during catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2012;23(2):147–54.

    PubMed  Article  Google Scholar 

  440. 440.

    Zellerhoff S, Lenze F, Eckardt L. Prophylactic proton pump inhibition after atrial fibrillation ablation: is there any evidence? Europace. 2011;13(9):1219–21.

    PubMed  Article  Google Scholar 

  441. 441.

    Zellerhoff S, et al. Fatal course of esophageal stenting of an atrioesophageal fistula after atrial fibrillation ablation. Heart Rhythm. 2011;8(4):624–6.

    PubMed  Article  Google Scholar 

  442. 442.

    Khan M, et al. Medical treatments in the short term management of reflux oesophagitis. Cochrane Database Syst Rev. 2007;2:CD003244.

    Google Scholar 

  443. 443.

    Kahrilas PJ. Clinical practice. Gastroesophageal reflux disease. N Engl J Med. 2008;359(16):1700–7.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  444. 444.

    Shaheen NJ, et al. Pantoprazole reduces the size of postbanding ulcers after variceal band ligation: a randomized, controlled trial. Hepatology. 2005;41(3):588–94.

    CAS  PubMed  Article  Google Scholar 

  445. 445.

    Halm U, et al. Thermal esophageal lesions after radiofrequency catheter ablation of left atrial arrhythmias. Am J Gastroenterol. 2010;105(3):551–6.

    PubMed  Article  Google Scholar 

  446. 446.

    Knopp H, et al. Incidental and ablation-induced findings during upper gastrointestinal endoscopy in patients after ablation of atrial fibrillation: a retrospective study of 425 patients. Heart Rhythm. 2014;11(4):574–8.

    CAS  PubMed  Article  Google Scholar