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Practice Patterns of Operators Participating in the Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) Registry

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The Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) is a multicenter prospective registry of atrial fibrillation (AF) ablation. We sought to describe the baseline workflows of REAL-AF operators.


REAL-AF enrolls high volume minimum fluoroscopy radiofrequency ablators. A 150 item questionnaire was administered to participating operators. Responses were analyzed using standard methods.


Forty-two respondents had a mean 178.2 ± 89.2 yearly AF ablations, with 42.4 ± 11.9% being paroxysmal (PAF). Most operators performed ablation with uninterrupted or minimally interrupted anticoagulation (66.7% and 28.6%). Left atrial appendage (LAA) thrombus was most commonly ruled out with transesophageal echocardiography (33.3% and 42.9% for PAF and persistent AF). Consistent with registry design, radiofrequency energy (92.1% ± 18.8% of cases) and zero fluoroscopy ablation (73.8% goal 0 fluoroscopy) were common. The majority of operators relied on index-guided ablation (90.5%); Mean Visitag surpoint targets were higher anteriorly vs posteriorly (508.3 ± 49.8 vs 392.3 ± 37.0, p < 0.01), but power was similar. There was considerable heterogeneity related to gaps in current knowledge, such as lesion delivery targets and sites of extra-pulmonary vein ablation (most common was the posterior wall followed by the roof). Peri-procedural risk factor management of obesity, hypertension, and sleep apnea was common. There was a mean of 3.0 ± 1.2 follow-up visits at 12 months.


REAL-AF operators were high volume low fluoroscopy “real world” operators with good follow-up and adherence to known best-practices. There was disagreement related to knowledge gaps in guidelines.

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The REAL-AF Registry is an investigator initiated study which is sponsored by Heart Rhythm Clinical and Research Solutions and funded by Biosense-Webster. There was no funding provided for the specific analysis presented here.

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Correspondence to Omar Kreidieh.

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Ethical/IRB approval

The Brookwood Baptist Health System Institutional Review Board (IRB) originally granted a waiver of informed consent and authorization for analysis and publication of data from the REAL-AF registry on April 5, 2016. Due to subsequent closure of this IRB, the project was transferred to and approved by the Western Institutional Review Board (WIRB) on October 31, 2018. The current analysis utilizes physician surveys on practice patterns and does not include direct patient data.


Joshua Silverstein – Consulting and Honoraria Biosense Webster, Medtronic.

J Osorio is a paid consultant for Biosense Webster, Inc., Galaxy Medical, Medtronic and Boston Scientific Allyson Varley- employed by HRCRS/REAL-AF.

The REAL-AF Registry is sponsored by Heart Rhythm Clinical and Research Solutions and funded by Biosense-Webster. There was no funding provided for the analysis presented here.

No other conflicts of interest to disclose.

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Kreidieh, O., Varley, A.L., Romero, J. et al. Practice Patterns of Operators Participating in the Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) Registry. J Interv Card Electrophysiol 65, 429–440 (2022).

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