This document discusses various non-pharmacological treatment options for atrial fibrillation (AFib), including catheter ablation procedures and implantable devices. It provides details on complete AV node ablation and pacemaker placement, which involves ablating the AV node to control ventricular rate and implanting a permanent pacemaker to avoid pacemaker dependence. The document summarizes the advantages and disadvantages of this approach and guidelines for appropriate candidates. It also discusses focal catheter ablation of AF triggers within the pulmonary veins and techniques for pulmonary vein isolation.

1. Non-pharmacological
Management of Atrial
Fibrillation
BY- DR SARITA CHOUDHARY

2. • AF is a supraventricular tachyarrhythmia with
uncoordinated atrial activation and consequently
ineffective atrial contraction Electrocardiogram (ECG)
include: 1) irregular R-R intervals 2) absence of distinct
repeating P waves, and 3) irregular atrial activity.
• Most frequent sustained arrhythmia of clinical
significance.
• It may occur due to reversible factors such as alcohol
ingestion, hyperthyroidism,or pulmonary embolism.
• In 70-80% of patients, atrial fibrillation is associated with
organic heart disorders coronary heart disease,
hypertension with left ventricular hypertrophy, valve
disease, or congenital heart defects.

3. • Symptoms range from no symptoms to fatigue,
palpitations, dyspnea, hypotension, syncope, or HF
• Nonvalvular AF increases the risk of stroke 5 times
and AF in the setting of mitral stenosis increases the
risk of stroke 20 times over patients in sinus rhythm.
• Thromboembolism occurring with AF is associated
with a greater risk of recurrent stroke, more severe
disability, and mortality . Silent AF is also associated
with ischemic stroke.
• AF is also associated with a 3-fold risk of HF and 2-
fold increased risk of both dementia and mortality.

4. AF Definitions: A Simplified Scheme
• Paroxysmal AF - AF that terminates spontaneously or with
intervention within 7 d of onset. Episodes may recur with
variable frequency.
• Persistent AF - Continuous AF that is sustained >7 d.
• Longstanding persistent AF- Continuous AF of >12 mo
duration.
• Permanent AF - Permanent AF is used when there has been a
joint decision by the patient and clinician to cease further
attempts to restore and/or maintain sinus rhythm
• Nonvalvular AF -AF in the absence of rheumatic mitral
stenosis, a mechanical or bioprosthetic heart valve, or mitral
valve repair.

5. Mechanism of AF

6. Treatment Options for AFib
Cardioversion
• Pharmacological
• Electrical
Drugs to prevent AFib
• Antiarrhythmic drugs
• Non-antiarrhythmic drugs
Drugs to control ventricular rate
Drugs to reduce thromboembolic risk
Non-pharmacological options
• Electrical devices (implantable pacemaker and defibrillator)
• AV node ablation and pacemaker implantation (ablate & pace)
• Catheter ablation
• Surgery (Maze, mini-Maze)

7. • The interest for non-pharmacological therapy has
emerged due to the limited antiarrhythmic drugs
and their frequent proarrhythmic effects.
• Thus, reasons for choosing nonpharmacological
therapy may be paroxysmal atrial fibrillation with
very frequent attacks and severe symptoms,
chronic atrial fibrillation without adequate rate
control leaving the patient at risk of developing
tachycardiomyopathy, or patients who experience
intolerable side effects of otherwise effective drug
therapy.

8. Electrophysiologic Mechanisms
• AF requires both a trigger for initiation and an appropriate
anatomic substrate for maintenance, both of which are
potential targets for therapy.
• Triggers of AF- Ectopic focal discharges often initiate AF
Rapidly firing foci initiating paroxysmal AF arise most
commonly from LA myocardial sleeves that extend into the
pulmonary veins. These observations led to the
development of pulmonary vein isolation as the
cornerstone for radiofrequency catheter ablation strategies
• Although the pulmonary veins are the most common sites
for ectopic focal triggers, triggers can also arise elsewhere,
including the posterior LA, ligament of Marshall, coronary
sinus, venae cavae, septum, and appendages.

9. • Atrial myocardial fibers are oriented in disparate directions
around the pulmonary veins and the posterior LA, with
considerable anatomic variability among individuals.
• Conduction abnormalities that promote re-entry are likely
due to relatively depolarized resting potentials in
pulmonary vein myocytes.
• Re-entry is further favored by abbreviated action
potentials and refractoriness in pulmonary vein myocytes
• Isolated pulmonary vein myocytes also demonstrate
abnormal automaticity and triggered activity that could
promote rapid focal firing.

10. • Maintenance of AF-Theories proposed to explain the
perpetuation and maintenance of AF include
1) multiple independent re-entrant wavelets associated
with heterogeneous conduction and refractoriness
2) ≥1 rapidly firing foci and
3) ≥1 rotors, or spiral wave re-entrant circuits. With a
single rapid focus or rotor excitation, wave fronts may
encounter refractory tissue and break up during
propagation, resulting in irregular or fibrillatory
conduction). Both rapid focal firing and re-entry may
be operative during AF.

11. • These presumed mechanisms have driven the
development of therapies.
• The atrial maze procedure and ablation lines may
interrupt paths for multiple wavelets and spiral re-entry.
• Using a biatrial phase mapping approach, a limited
number of localized, rapid drivers were identified in a
small group of patients with various types of AF . *
• In most cases, these localized sources appeared to be
reentrant, while in others they were consistent with focal
triggers and radiofrequency catheter ablation targeting of
these sites often terminated or slowed AF.
• Narayan SM, Krummen DE, Shivkumar K, 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;60:628-36.

12. Summary of Recommendations for Rate Control

14. Recommendations for Electrical and Pharmacological Cardioversion of AF and
Atrial Flutter

16. Summary of Recommendations for Prevention of Thromboembolism in Patients
With AF

18. SurgeryElectrophysiologicalDevices
Pacemaker
(single or dual chamber)
Internal atrial
defibrillators
Catheter ablation
AV node ablation
Non-Pharmacological Treatment
Options for AFib
Maze procedure
Modified Maze
(mini-Maze)
ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation
J Am Coll Cardiol (2006) 48: 854

19. Various non-pharmacological treatment modalities for
atrial fibrillation

20. Therapeutic goals for non-pharmacological treatment of atrial
fibrillation

21. Complete AVN ablation + Pacemaker
Placement

22. Atrioventricular Junction Ablation
• Transvenous ablation of the atrioventricular (AV)
junction was first performed with direct-current
shocks in 1981.
• Radiofrequency energy replaced direct-current
shocks for AV junction ablation because of
improved efficacy and safety.
• advantage is its success rate approaches 100%.
• It is associated with a low incidence of adverse
effects.

23. • AV nodal ablation with permanent pacemaker implantation
effectively controls and regularizes ventricular heart rate
• Patients most likely to benefit include those with
tachycardia- induced cardiomyopathy with ventricular rate
control refractory to medical therapy .
• It is usually reserved for elderly patients as it leads to
pacemaker dependency.
• Patients with symptoms refractory to medical therapy who
are treated with AV nodal ablation and permanent
pacemaker implantation have an improvement in cardiac
symptoms, quality of life, ventricular function and health
care utilization.*
• Brignole M, Menozzi C, Gianfranchi L, et al. Assessment of atrioventricular junction ablation and VVIR pacemaker versus pharmacological treatment in patients with
heart failure and chronic atrial fibrillation: a randomized, controlled study. Circulation. 1998;98:953-60.
• Kay GN, Ellenbogen KA, Giudici M, et al. The Ablate and Pace Trial: a prospective study of catheter ablation of the AV conduction system and permanent pacemaker
implantation for treatment of atrial fibrillation. APT Investigators. J Interv Card Electrophysiol. 1998;2:121-35

24. • With this approach, no rate control medications are
necessary, but anticoagulation to prevent
thromboembolism is required as atrial systole is not
restored ,based on the patient’s stroke risk as assessed
by the CHA2DS2-VASc system.
• Lifelong pacemaker dependency with its potential
complications.
• Time-permitting, pacemaker implantation may be
performed 4 to 6 weeks prior to the AV node ablation
to ensure proper pacemaker function as malfunction
due to lead dislodgement can be catastrophic.
• Postablation, the ventricular pacing rate is usually set
between 90 bpm and 100 bpm and then gradually
tapered over several months

25. • Sudden death secondary to torsades de pointes or
ventricular fibrillation has been reported after AV
junction ablation. This outcome is possibly related to
increased dispersion of ventricular refractoriness
produced by sudden heart rate slowing and
ventricular pacing
• RV apical pacing also creates a ventricular activation
sequence that can lead to depressed ventricular
function.* In patients with left ventricular ejection
fraction (LVEF) <35% and symptoms of HF,
implantation of a biventricular pacing system is
recommended.
• Curtis AB, Worley SJ, Adamson PB, et al. Biventricular pacing for atrioventricular block and systolic dysfunction. N Engl J Med. 2013;368:1585-93.

26. Advantages:
100% efficacy
85% symptomatic improvement
Eliminates need for rate control drugs
Disadvantages:
Pacemaker dependant
Need for anticoagulation
Good Candidates:
Tachy / Brady Syndrome
CHF with BiV device
Medication refractory / intolerant
Elderly
ACC/AHA 2014 AF guideline
• AV nodal ablation with permanent ventricular pacing is reasonable to
control the heart rate when pharmacological therapy is inadequate and
rhythm control is not achievable -Class IIa(Level of Evidence: B)
• Class III: Harm -AV nodal ablation with permanent ventricular pacing should
not be performed to improve rate control without prior attempts to achieve
rate control with medications

27. AV Node Modification
• The objective of partial AV node ablation is to modify the conduction properties
slowing the ventricular rate in AF without the need for pacemaker dependency.
• Unfortunately, AV node modification is technically difficult and long-term results
often unpredictable.
• Radiofrequency energy applied to the right posterior or midseptal regions results in
a significant and sustained reduction in ventricular rate during AF in 60% to 85% of
patients.
• But it is associated with a 21% incidence of either early or late AV block.
• Compared with AV junction ablation, the advantage of AV node modification is the
achievement of rate control during AF without the need for long-term pacing.
• However, it has not achieved widespread use because of a high recurrence rate and
because symptoms caused by an irregular rhythm may persist.
• An attempt at AV node modification is most appropriate in patients who are
appropriate candidates for AV junction ablation and who wish to avoid pacemaker
implantation.
• Because of a high risk of AV block, AV node modification should not be
recommended in patients who consider the possibility of pacemaker implantation
unacceptable.
• Williamson BD, Man CK, Daoud E, et al. Radiofrequency catheter modification of atrioventricular conduction to control the ventricular rate during atrial fibrillation. N Engl J Med.
1994;331:910 –917

28. Atrial Pacing to Prevent AF
Vagotonic AF
• Coumel et al* demonstrated the efficacy of atrial pacing in patients with AF
of vagal origin. These patients have AF triggered by sinus bradycardia or
atrial bigeminy, usually at rest, during sleep, or after meals.
• Patients with sick sinus syndrome may need a pacemaker to prevent severe
bradycardia with syncope. Atrial fibrillation is a common part of the sick
sinus syndrome (tachy-bradyarrhythmia).
• Antiarrhythmic therapy may exacerbate sick sinus syndrome and require
pacemaker implantation.
• Atrial pacing prevents long pauses and atrial escape beats, which may
trigger atrial fibrillation and atrioventricular synchrony is possible
• Atrial pacing cannot be justified on the basis of existing data in patients with
nonvagotonic AF or those without sinus node disease.
*Coumel P, Friocourt P, Mugica J, et al. Long-term prevention of vagal atrial arrhythmias by atrial pacing at 90/minute: experience with 6 cases.
Pacing Clin Electrophysiol. 1983;6:552–560.

29. • Dual-site atrial pacing (left atrial pacing was achieved by an
electrode in the middle or distal part of the coronary sinus)
results in more homogeneous atrial depolarization and
repolarization than conventional pacing, and it is more
efficacious than single-site pacing for preventing AF.*
• The primary role of pacemakers in the treatment of patients
with AF is for treatment of symptomatic bradycardia, which is
often related to underlying sick sinus syndrome.
• For patients with sick sinus syndrome who need pacing, atrial
or dual chamber pacing significantly decreases the incidence
of subsequent AF compared with RV pacing.**
• Friedman PA, Hill MRS, Hammill SC, et al. Randomized prospective pilot study of long-term dual-site atrial pacing for prevention
of atrial fibrillation. Mayo Clin Proc. 1998;73:848–854.
**Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS Focused Update Incorporated Into the ACCF/AHA/HRS 2008 Guidelines
for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol.
2013;61:e6-e75.

30. Focal Catheter Ablation of AF
• There are 2 different types of
arrhythmias that may play a role in
generating AF, and both may be
addressed by focal ablation.
• One type of arrhythmia is a
premature depolarization that
initiates AF.
• A second type is a focal tachycardia
that either induces fibrillation in the
atria or mimics AF by creating a
pattern of rapid and irregular
depolarization wavefronts in the
atria.

31. • Although focal sources of AF may be found in the right
atrium, left atrium, coronary sinus, superior vena cava, or
vein of Marshall, 95% of foci are located within a
pulmonary vein.
• The pulmonary veins are covered by myocardial sleeves
formed by one or more layers of myocardial fibers
oriented in circular, longitudinal, oblique, or spiral
directions. These sleeves vary from 2 to 25 mm in length,
with a mean length of '10 to 20 mm in the superior
pulmonary veins and 5 to 10 mm in the inferior pulmonary
veins.
• The difference in the length of the sleeves may explain
why arrhythmogenic foci are found more often in the
superior than in the inferior pulmonary veins.

32. • The arrhythmogenic nature of these myocardial
sleeves may be due in part to their embryonic
origin from the same substrate that gives rise to
the conduction system, which may be subject to
abnormal automaticity.
• However, it is unclear whether the arrhythmias
that arise in pulmonary veins are most often due
to automaticity, reentry, or triggered activity, and
it is possible that more than one mechanism
plays a role in generating these arrhythmias.

33. Focal Ablation Within Pulmonary Veins
• One approach to the ablation of a pulmonary vein
arrhythmia that triggers or simulates AF is to target the
site of origin of the arrhythmia within the pulmonary vein
directly.
• Localization of the site of origin of the arrhythmia is
guided by the endocardial activation time
• The most common complications associated with the focal
ablation of arrhythmias arising within the pulmonary veins
are pericardial effusion (4%), transient ischemic episodes
(2%), and symptomatic pulmonary vein stenosis (2%)
• The early experience with the focal ablation of pulmonary
vein arrhythmias indicates that the recurrence rate is high
and the success rate only modest, even in experienced
laboratories.

34. Pulmonary Vein Isolation
• Electrically isolating the pulmonary veins by circumferential
ablation at their ostia.
• This would be effective in preventing recurrent AF caused by
multiple pulmonary vein foci, even if new foci emerge at
some future time.
• Two techniques have been used to isolate pulmonary veins
electrically. One technique involves the delivery of multiple,
contiguous point applications of radiofrequency energy in a
circumferential fashion in the left atrium near the ostia of the
pulmonary veins.
• Another technique uses ultrasound energy to create a
circumferential lesion with a catheter that has an ultrasound
transducer mounted near its tip. The transducer is inside an
inflatable balloon that is used to occlude the pulmonary vein
and to stabilize the transducer at the left atrial–pulmonary
vein junction.

35. • Presently, empirically isolate all four PVs not at the ostium but outside
the tubular portion of the PV to avoid the risk of venous stenosis and
improve procedural efficacy.
• Because the PV is funnel-shaped with a large proximal end (referred to
as the antrum), which blends into the posterior wall of the LA.
• Success rates for catheter-based ablation are lower in patients with
persistent atrial fibrillation than paroxysmal AF.
• Antral encirclement of PVs in cases with long-standing persistent AF
underwent a single- procedure, showed a drug-free success rate ranging
from 37% to 56% at approximately 1 year .Integration of repeat
procedures increased the drug-free success rate to 59%. The
combination of drugs and multiple procedures yielded a success rate of
approximately 77%. *
• In addition, the chances of a successful outcome are lower in those
with marked dilation of the left atrium.
• Brooks AG, Stiles MK, Laborderie J, et al. Outcomes of long-lasting persistent atrial fibrillation ablation: a systematic review. Heart Rhythm
2010;7: 835–46

36. Segmental Isolation of Pulmonary Veins
• The myocardial fibers that envelope the pulmonary veins may not be
present along the entire circumference of the pulmonary vein ostia.
• Therefore, to eliminate conduction in and out of a pulmonary vein,
ablation along the entire circumference of the ostium may not be
necessary.
• Instead, radiofrequency energy can be targeted to the segments of the
ostium at which muscle fibers are present.
• These sites are identified by the presence of high-frequency
depolarizations, which likely represent pulmonary vein muscle
potentials which may encompass as little as 25% of the circumference
of the ostium .
• If no ectopy is present during the ablation procedure, it may be
appropriate to perform empiric segmental isolation of the left and right
superior and left inferior pulmonary veins, because these are the most
common sources of the arrhythmias that trigger AF.

37. • Success rate of 90% in patients with paroxysmal AF and
with minimal or no risk of pulmonary vein stenosis.
• The end point of the procedure is to electrically isolate the
pulmonary veins - pulmonary vein isolation or PVI.
• Major advantages of this technique are that it eliminates
the need for detailed mapping of all pulmonary vein foci
and the procedure can be performed with conventional
ablation catheters and does not require specialized tools
such as a balloon ultrasound ablation catheter.
• At present, the best candidates for the elimination of focal
triggers of AF are symptomatic, drug-refractory patients
with paroxysmal AF and normal or only mildly enlarged left
atria.

38. Variations in the pulmonary vein isolation methods. (A) CPVA/CPVI
(Circumferential PV ablation/isolation), (B) EEPVI (Extensive encircling PV
isolation), (C) PVAI (PV antrum isolation), and (D) BOX isolation

39. ablation procedure.-
• Systemic anticoagulation was achieved in all patients with intravenous
heparin (5000 to 20000 IU) to maintain a partial thromboplastin time of 60
to 90 seconds during the procedure.
• Before ablation, all patients underwent a 24-hour Holter monitoring.
• Transoesophageal echocardiography was performed in all patients in order
to exclude left atrial thrombus, one day before the procedure
• Mandatory ablation lines are shown in blue and optional lines in orange.
• Transseptal access to the left atrium is done by standard technique.
• Percutaneous transvenous radiofrequency catheter ablation is done under
the guidance of the computer-based mapping system
• Ablation around both left- and right-sided pulmonary veins (1) is
mandatory, and is done using an irrigated catheter (Navistar Cool Floww)
or an 8 mm non-irrigated catheter (Navistar DSw) with a maximum energy
settings at 40 W/ 558C/17 mL saline/min, alternatively 80 W/558C (8-mm
tip).
• Care is taken to avoid excessive heating of the posterior wall of the left
atrium—maximum energy 30 W/558C/17 mL saline/ min alternatively 50
W/558C (8 mm tip).

40. A ‘roof line’ between
the two ablated areas (2) is obligatory,
whereas an ablation line from left inferior
pulmonary vein to mitral annulus is optional
(3).
These lines consisted of
contiguous focal lesions deployed at a
distance >5 mm from the ostia.
With a maximum temperature setting of
60°C, RF energy (upto 50 W) was applied for
60 to 120 seconds until local electrogram
amplitude was reduced by 80%
The radiofrequency ablation procedural
endpoint is elimination of high-frequency
electric activity (.0.2 mV) inside the encircled
areas, either documented by CARTO-mapping
or by the use of Lasso catheter.

41. s
Left atrium obtained by multislice computed tomography segmentation and non-fluoroscopic navigation after atrial fibrillation ablation
(circumferential
pulmonary vein isolation) ABL, ablation catheter; CC circular catheter; CSC, coronary sinus catheter; LAA, left atrial appendage; LIPV, left
inferior pulmonary vein;
LSPV, left superior pulmonary vein; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein

43. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized
trial.
JAMA. 2014 Jun 11;311(22):2337.
• OBJECTIVE:
To compare radiofrequency ablation with antiarrhythmic drugs (standard therapy) in treating patients with paroxysmal AF as a
first-line therapy.
• DESIGN, SETTING, AND PATIENTS:
A randomized clinical trial involving 127 treatment-naive patients with paroxysmal AF were randomized at 16 centers in Europe
and North America to received either antiarrhythmic therapy or ablation.
• INTERVENTIONS:
Sixty-one patients in the antiarrhythmic drug group and 66 in the radiofrequency ablation group were followed up for 24
months.
• MAIN OUTCOMES AND MEASURES:
The time to the first documented atrial tachyarrhythmia of more than 30 seconds (symptomatic or asymptomatic AF, atrial
flutter, or atrial tachycardia), detected by either scheduled or unscheduled electrocardiogram, Holter, transtelephonic monitor,
or rhythm strip, was the primary outcome. Secondary outcomes included symptomatic recurrences of atrial tachyarrhythmias
and quality of life measures assessed by the EQ-5D tool.
• RESULTS:
Forty-four patients (72.1%) in the antiarrhythmic group and in 36 patients (54.5%) in the ablation group experienced the
primary efficacy outcome (hazard ratio [HR], 0.56 [95% CI, 0.35-0.90]; P = .02). For the secondary outcomes, 59% in the drug
group and 47% in the ablation group experienced the first recurrence of symptomatic AF, atrial flutter, atrial tachycardia (HR,
0.56 [95% CI, 0.33-0.95]; P = .03). No deaths or strokes were reported in either group; 4 cases of cardiac tamponade were
reported in the ablation group. In the standard treatment group, 26 patients (43%) underwent ablation after 1-year. Quality of
life was moderately impaired at baseline in both groups and improved at the 1 year follow-up. However, improvement was not
significantly different among groups.
• CONCLUSIONS AND RELEVANCE:
Among patients with paroxysmal AF without previous antiarrhythmic drug treatment, radiofrequency ablation compared with
antiarrhythmic drugs resulted in a lower rate of recurrent atrial tachyarrhythmias at 2 years. However, recurrence was frequent
in both groups.

44. • The evidence supporting the efficacy of catheter ablation is strongest for
paroxysmal AF in younger patients with little to no structural heart disease
and in procedures performed in highly experienced centers. *
• Studies have demonstrated a reduction of AF related symptoms in these
contexts .Evidence is insufficient to determine whether AF catheter ablation
reduces all-cause mortality, stroke, and HF . **
• Ongoing clinical trials (CABANA [Catheter Ablation Versus Antiarrhythmic Drug
Therapy for Atrial Fibrillation] and EAST [Early Therapy of Atrial Fibrillation for
Stroke Prevention Trial]) should provide new information for assessing
whether AF catheter ablation is superior to standard therapy with either rate-
or rhythm-control drugs for reducing total mortality and other secondary
outcome measures, and whether early application of a rhythm-control therapy
involving ablation, antiarrhythmic drugs, or both, can impact endpoints of
stroke, cardiovascular death, or HF compared with usual care.
• Packer DL, Kowal RC, Wheelan KR, 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;61:1713-23.
** Leong-Sit P, Zado E, Callans DJ, et al. Efficacy and risk of atrial fibrillation ablation before 45 years of age. Circ Arrhythm Electrophysiol. 2010;3:452-7.

46. • The decision whether to pursue catheter ablation depends on a
large number of variables, including the type of AF (paroxysmal
versus persistent verses longstanding persistent), degree of
symptoms, presence of structural heart disease, candidacy for
alternative options such as rate control or antiarrhythmic drug
therapy, likelihood of complications, and patient preference .
• It is important to recognize that most patients enrolled in trials
of AF catheter ablation have generally been younger, healthy
individuals with symptomatic paroxysmal AF refractory to ≥1
antiarrhythmic medication.
• The safety and efficacy of catheter ablation are less well
established for other populations of patients, especially
patients with longstanding persistent AF, very elderly patients,
and patients with significant HF including tachycardia-induced
cardiomyopathy

47. • Recurrences of AF after catheter ablation are common
during the first 3 months.*
• When AF occurs early after catheter ablation, a
pharmacologic rhythm control approach rather than early
repeat ablation should be considered or may require
cardioversion.
• Recurrent AF after 3 months is usually an indication of
recovery of pulmonary vein conduction and may respond
to repeat ablation or initiation of an antiarrhythmic drug.
• Recurrence of AF following ablation is 3- to 7-fold more
likely to be asymptomatic compared with prior to ablation
and late recurrences of AF can occur.
• Calkins H, Kuck KH, Cappato R, 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: a report
of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Heart Rhythm. 2012;9:632-96.

48. • Because of the well-established risk of periprocedure
stroke or TIA associated with AF catheter ablation,
anticoagulation is indicated to prevent thromboembolism
regardless of the patient’s baseline thromboembolic risk.
• Both intraprocedural heparin and oral anticoagulation
(warfarin) for ≥2 months postprocedure are recommended.
• AFcatheter ablation should not be performed in patients
who cannot be treated with anticoagulant therapy.
• Continuation of anticoagulation >2 months following AF
catheter ablation, should be based on consideration of the
patient's thromboembolic risk profile bleeding risk, and
patient choice

49. Complications Following AF Catheter Ablation
• A 2010 international survey of radiofrequency catheter
ablation procedures reported a 4.5% incidence of major
complications, including a 1.3% rate of cardiac tamponade, a
0.94% rate of stroke or TIA, a 0.04% rate of atrial-esophageal
fistula, and a 0.15% rate of death . *
• An estimated 93 801 AF ablations were performed from 2000 to
2010. The overall frequency of complications was 6.29% with
combined cardiac complications (2.54%) being the most
frequent. Cardiac complications were followed by vascular
complications (1.53%), respiratory complications (1.3%), and
neurological complications (1.02%). The in-hospital mortality
was 0.46%.**
• Factors associated with complication rates include older age,
female sex, and a CHADS2 score of ≥2.
• Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human
atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3:32-8.
** In-Hospital Complications Associated With Catheter Ablation of Atrial Fibrillation in the United States Between 2000 and 2010 Analysis of 93
801 Procedures Circulation. 2013;128:2104-2112.)

51. AF Catheter Ablation to Maintain Sinus Rhythm:
Recommendations ACC/AHA 2014
Class I
1. AF catheter ablation is useful for symptomatic paroxysmal AF refractory
or intolerant to at least 1 class I or III antiarrhythmic medication when
a rhythm control strategy is desired (Level of Evidence: A)
2. Prior to consideration of AF catheter ablation, assessment of the
procedural risks and outcomes relevant to the individual patient is
recommended. (Level of Evidence: C)
Class IIa
1. AF catheter ablation is reasonable for selected patients with
symptomatic persistent AF refractory or intolerant to at least 1 class I
or III antiarrhythmic medication (Level of Evidence: A)
2. In patients with recurrent symptomatic paroxysmal AF, catheter
ablation is a reasonable initial rhythm control strategy prior to
therapeutic trials of antiarrhythmic drug therapy, after weighing risks
and outcomes of drug and ablation therapy (Level of Evidence: B)

52. Class IIb
• 1. AF catheter ablation may be considered for symptomatic long-
standing (>12 months) persistent AF refractory or intolerant to at least
1 class I or III antiarrhythmic medication, when a rhythm control
strategy is desired (Level of Evidence: B)
2. AF catheter ablation may be considered prior to initiation of
antiarrhythmic drug therapy with a class I or III antiarrhythmic
medication for symptomatic persistent AF, when a rhythm control
strategy is desired. (Level of Evidence: C)
Class III: Harm
1. AF catheter ablation should not be performed in patients who
cannot be treated with anticoagulant therapy during and following
the procedure (Level of Evidence: C)
2. AF catheter ablation to restore sinus rhythm should not be performed
with the sole intent of obviating the need for anticoagulation. (Level
of Evidence: C)

54. Current State of Curative
Catheter-Based RFA
Who is a good candidate?
Symptomatic / Frequent AF
Limited Heart Dz
EF > 35%
LA < 5.5cm
No MS / Rheumatic Dz
Younger Patients
• No LA thrombus ( absolute contraindication to catheter
ablation is left atrial thrombus). Because of the risk of
dislodging an existing thrombus during the procedure and
causing a stroke
Medically Refractory / Intolerant
(Ablation now second line therapy)

55. A-Fib vs. EP Labs

56. Internal Atrial Defibrillator
• An implantable atrial defibrillator in theory is an excellent modality for
the detection and rapid conversion of AF.
• It involves putting in transvenous leads in the right atrium and also in
coronary sinus which are connected to the defibrillator located
subcutaneously in the infraclavicular region.
• The device is usually triggered at a preset delivery energy varying from
0.1 to 10.0 joules. However, a majority of patients reported significant
discomfort with energy >2.0 joules.
• Safe and have an 80% efficacy in terminating AF.
• The drawbacks include discomfort from the shocks, early recurrence of
AF, and technical problems with the device.
• Because frequent shocks are undesirable, the ideal candidate for an
implanted atrial defibrillator has infrequent episodes of symptomatic,
drug-refractory AF. However, if episodes of AF are rare, it is difficult to
justify implanting a device.
• At present, the implanted atrial defibrillator is available only in
combination with a ventricular defibrillator.

57. Nonpharmacologic Stroke Prevention
• A combination of the LAA’s unique geometry and atrial fibrillation leads to
low blood flow velocity and stasis, which are precursors to thrombus
formation.
• Only 50–60% of patients who clinically should be prescribed warfarin are
actually taking it
• 14-44 % of AF patients have a contraindication to anticoagulation
• Even with adequate anticoagulation, the risk of stroke is not abolished.
• The annual incidence of stroke in patients therapeutically warfarinised
is 2–5%
• Thus increased interest in alternative treatment strategies to help reduce
the risk of stroke in these patients.
• The main focus of this interest is on the left atrial appendage (LAA) as It
has been shown that more than 90% of thrombi in patients with
nonrheumatic, nonvalvular AF are located within this cavity

58. Percutaneous Approaches to Occlude the LAA
• Exclusion of the LAA, both surgically and with
devices, has been attempted with the goal of
reducing thromboembolism in patients with AF.
• There are 2 general approaches to occlude the
LAA using percutaneous approaches. The first
strategy involves implantable devices that are
inserted percutaneously into the LAA with the
goal of occluding or plugging the LAA. Devices
for LAA occlusion include the WATCHMAN
Device and the Amplatzer Cardiac Plug.

59. • The WATCHMAN device is a
percutaneous left atrial
appendage closure system
delivered via a transseptal
approach, and implanted at or
immediately distal to the ostium
of the left atrial appendage.
• The device consists of a self-
expanding nitinol frame with
fixation barbs and a permeable
polyester fabric which covers the
atrial facing device surface.
• Available in 5 sizes ranging from
21mm to 33mm in diameter: 21,
24, 27, 30, 33 mm with device
sizing and placement guided by
fluoroscopy and
transesophageal
echocardiography

60. WATCHMAN LAA Closure Device in situ
3000838-18

61. PROTECT AF trial
• Prospective, randomized study of WATCHMAN LAA Device vs. Long-term Warfarin Therapy
• 2:1 allocation ratio device to control
• Key Inclusion Criteria
• Age 18 years or older
• Documented non-valvular AF
• Eligible for long-term warfarin therapy, and no other conditions that would require long-
term warfarin therapy
• Calculated CHADS2 score > 1
• 800 Patients enrolled from Feb 2005 to Jun 2008
– Device Group (463)
– Control Group (244)
– Roll-in Group (93)
• 59 Enrolling Centers (U.S. & Europe)
• Follow-up Requirements
– TEE follow-up at 45 days, 6 months and 1 year
– Clinical follow-up biannually up to 5 years
– Regular INR monitoring while taking warfarin
Reddy VY, Doshi SK, Siever H, et al. Percutaneous Left Atrial Appendage Closure for Stroke Prophylaxis in Patients with Atrial Fibrillation:
2.3 Year Follow-Up of the PROTECT AF Trial (Watchman left atrial appendage system for embolic protection in patients with atrial
fibrillation) trial. Circulation. 2013;127:720-9

62. • Primary Efficacy Endpoint
• All stroke: ischemic or hemorrhagic
• Cardiovascular and unexplained death: includes sudden death, MI,
CVA, cardiac arrhythmia and heart failure
• Systemic embolization
• Primary Safety Endpoint
• Device embolization requiring retrieval
• Pericardial effusion requiring intervention
• Cranial bleeds and gastrointestinal bleeds
• RESULTS- hemorrhagic stroke risk is significantly lower with the device.
• When hemorrhagic stroke occurred, risk of death was markedly increased
• Noninferiority to warfarin for the composite endpoint of stroke, systemic
embolism, and cardiovascular death;
• however, early adverse events occur in approximately 10% of patients including
pericardial bleeding

63. • After WATCHMAN device placement continue
aspirin 81–325 mg daily indefinitely and
clopidegrel 75 mg for 6 months.
• In light of the permeability of the device
membrane to blood, warfarin is prescribed with a
target International Normalised Ratio (INR) of 2.0
to 3.0 for a period of 45 days. Discontinued at 45
days if follow up TEE shows either complete
closure of the left atrial appendage <5mm of
peridevice flow.
• No infective endocarditis prophyaxis required.

64. • The second strategy is to tie off the LAA using an epicardial snare,
referred to as the LARIAT device. This device received FDA
approval in 2009 for facilitation of suture placement and knot
tying for use in surgical applications in which soft tissues are
being approximated. The initial experience **with this device
appeared promising, with 97% acute obliteration of the LAA as
confirmed by TEE and a favorable safety profile
• The LARIAT device’s long-term outcomes, requiring RCTs to study
reduced stroke risk and safety, are not yet defined.
• The device requires subxiphoid pericardial access that may not be
achievable in the presence of pericardial adhesions, it can
provoke pericarditis that can be severe, and it is not suitable for
all LAA anatomies.
• Aspirin continued indefinately , OAC given if no contraindication
** Bartus K, Han FT, Bednarek J, et al. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience. J Am Coll Cardiol.
2013;62:108-18.

65. • Amplatzer Cardiac Plug The device consists
of a lobe, designed to sit within the left
atrial appendage, and an occlusive disc,
which fits over the left atrial appendage
orifice. The lobe and disc are connected by
a central waist, with the lobe containing
hooks to ensure device position
• Successful device implantation achieved in
94% treated.
• Serious adverse outcomes occurred in
7.0% patients, including ischemic strokes,
device embolization and pericardial
effusions
• It has received European regulatory
approval and is available for clinical use in
Europe
• Park JW, Bethencourt A, Sievert H, et al. Left atrial appendage closure with Amplatzer cardiac plug in
atrial fibrillation: initial European experience. Catheter Cardiovasc Interv. 2011;77:700-6.

66. Surgical Treatment of AF
Maze Procedure
• The surgical maze procedure was introduced in 1987
• Creating anatomic barriers in the atria may decrease the
number of circulating wavelets to a level below the critical
number required to sustain AF and are often effective in
restoring and maintaining sinus rhythm long-term.
• It is typically performed in association with mitral valve or
coronary bypass surgery
• Another intraoperative approach is cryoablation limited to
the posterior left atrium. Linear cryolesions connecting the 4
pulmonary veins and the posterior mitral annulus were
effective in restoring sinus rhythm long-term in 69% of
patients with chronic AF.

67. Schematic drawing of the right and left
atria viewed from behind (below) or in
front (above), with an indication of the
surgical incisions that are created during
Maze III operation.
The Maze procedure is performed by isolating
the atrial appendages and cutting the atrial
walls in a specific pattern. Thereby, the
depolarization wave front is forced to follow
one specific path from the sinus node to the
atrioventricular node, and thus the atrial
contraction will be organised.
Since the first pubication the pattern of
incisions in the right atrium has been slightly
modified to avoid injury to the sinus node
artery leading to sinus node dysfunction
postoperatively
To shorten operative time, some
surgeons prefer to use cryoablation or
radiofrequency ablation by a handheld probe
instead of surgical incisions.

68. • 74% to 90% of patients are in sinus rhythm at 2 to 3 years postoperatiely. The
operative mortality rate is 1%, but up to 6% of patients have required a
pacemaker. In 90% of patients, the right and left atria regain mechanical
function.*
• The FAST (Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment)
trial compared the outcomes of catheter ablation and surgical ablation in a
randomized study design .Patients either had left atrial dilation and hypertension
(42 patients, 33%) or failed prior catheter ablation (82 patients, 67%). Freedom
from atrial arrhythmias was greater after surgical ablation compared with
catheter ablation, but the complication rate after surgical ablation was higher. **
• McCarthy PM, Gillinov AM, Castle L, et al. The Cox-Maze procedure: the Cleveland Clinic experience. Semin Thorac Cardiovasc Surg. 2000; 12:25–29.
• Cox JL, Ad N, Palazzo T, et al. Current status of the Maze procedure for the treatment of atrial fibrillation. Semin Thorac Cardiovasc Surg. 2000; 12:15–19
** Boersma LV, Castella M, van BW, et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical
trial. Circulation. 2012;125:23-30.

69. Linear Catheter Ablation of AF
• Attempts to replicate the results of the maze procedure in
the electrophysiology laboratory have consisted of the
creation of linear lesions in the left and/or right atria.
• The linear lesions have been produced either with
individual, contiguous applications of radiofrequency
energy on a point-by-point basis or with multiple catheters
with coil electrodes that are positioned against the atrial
wall.
• The most common complication reported are pericardial
effusion, which occurred 11% ,sinus node dysfunction (RA
abation ) in 8% of patients.
• Two serious types of complications limited to left atrial
ablation are cerebral infarction,reported in 8% ,pulmonary
vein stenosis, the incidence of which is unclear
• Haissaguerre M, Jais P, Shah DC, et al. Right and left atrial radiofrequency catheter ablation therapy of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol.
1996;7:1132–1144.

70. • Decisions regarding the choice of catheter-based or
surgical ablation must be made on the basis of patient
preference, and institutional experience and outcomes
with each therapy
Surgery Maze Procedures: Recommendations
• Class IIa- An AF surgical ablation procedure is
reasonable for selected patients with AF undergoing
cardiac surgery for other indications. (Level of
Evidence: C)
• Class IIb-A stand-alone AF surgical ablation procedure
may be reasonable for selected patients with highly
symptomatic AF not well managed with other
approaches (Level of Evidence: B)

71. Surgical excision of the LAA may be considered in patients
undergoing cardiac surgery. Class IIb (Level of Evidence: C)
• Removal of the LAA—yields inconsistent results and the
anatomy of the LAA is quite variable . The circumflex
coronary artery lies proximate to the base of the LAA and
epicardial and endocardial-based surgical techniques to
occlude the LAA are often inadequate because of surgeon
concern regarding damage to the circumflex artery
• The results of surgical occlusion of the LAA remain
suboptimal, with incomplete occlusion in ≥50% and
thrombus was identified in ≥25% of patients with
unsuccessful LAA occlusion .*So continued need for
anticoagulation in patients who have undergone surgical LAA
ligation.
• Kanderian AS, Gillinov AM, Pettersson GB, et al. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll
Cardiol. 2008;52:924-9.

72. Conclusion
• In the minority of patients in whom AF cannot be adequately managed by
pharmacological therapy, the most appropriate type of
nonpharmacological therapy must be selected on an individualized basis.
• For example, in a cardiomyopathy patient with chronic AF and an
uncontrolled ventricular rate, AV junction ablation may be the optimal
therapy.
• In a patient with the sick sinus syndrome, atrial-based pacing (perhaps
biatrial) may be the most appropriate option.
• In a patient who requires an implantable cardioverter-defibrillator and
whom has occasional episodes of AF, implantation of a device capable of
both atrial and ventricular defibrillation should be considered.
• If the patient has idiopathic AF, best technique currently available for
curing paroxysmal AF (assuming it originates from the pulmonary veins) is
segmental isolation of the pulmonary veins by discrete applications of
radiofrequency energy at the ostia, guided by pulmonary vein potentials.

73. • For ablation of long-standing persistent AF, there is a
consensus that PVI is the first-line approach, similar to
paroxysmal AF.
• Since ablation of chronic AF cases is still challenging, early
treatment of paroxysmal AF before transformation to the
persistent or chronic form is mandatory.
• In the occasional patient who is disabled by chronic AF,
referral for surgical treatment may be appropriate.
• However, at present, the most appropriate option for most
patients with idiopathic chronic AF may be the use of
pharmacological therapy to minimize symptoms as much
as possible, prevent tachycardia-induced cardiomyopathy,
and avoid thromboembolic complications.
• Nonpharmacological Approaches to Atrial Fibrillation Melvin M. Scheinman, MD; Fred Morady, MD Clinical Cardiology: New Frontiers Circulation April 24,
2001
• Current strategiesfornon-pharmacologicaltherapyoflong-standing persistentatrialfibrillation Teiichi Yamane,MD, Journal of Arrhythmia 28 (2012) 155–161

74. THANK U ....

83. Selected Risk Factors and Biomarkers for AF
• Increasing age
• Hypertension
• Diabetes mellitus
• MI
• VHD
• HF
• Obesity
• Obstructive sleep apnea
• Cardiothoracic surgery
• Smoking
• Exercise
• Alcohol use
• Hyperthyroidism
•Increased pulse pressure
•European ancestry
•Family history
•Genetic variants
Electrocardiographic
•LVH
Echocardiographic
•LA enlargement
•Decreased LV fractional shortening
•Increased LV wall thickness
Biomarkers
•Increased CRP
•Increased BNP