NON PHARMACOLOGICAL MANAGEMENT OF ATRIAL FIBRILLATION

1. Non-pharmacological Management
of Atrial Fibrillation
DR HARISH ORUGANTI

2. Importance..
• 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.
• AF is also associated with a 3-fold risk of HF and 2-fold increased risk of both
dementia and mortality.

3. 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)

4. • The interest for non-pharmacological therapy has emerged due to the limited
antiarrhythmic drugs and their frequent proarrhythmic effects.
• paroxysmal atrial fibrillation with very frequent attacks and severe symptoms
• chronic atrial fibrillation without adequate rate control -tachycardiomyopathy, or
• patients who experience intolerable side effects of otherwise effective drug therapy.

5. 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 MC 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.

6. • Atrial myocardial fibers are oriented in different 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.

7. • 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.

8. • 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.

9. 2016 ESC Guidelines for the management of atrial
fibrillation developed in collaboration with EACTS
and ESC/EHRA/ES0
European Heart Journal (2016) 37, 2893–2962

10. 2016 ESC Guidelines for the management of atrial
fibrillation developed in collaboration with EACTS
and ESC/EHRA/ES0
European Heart Journal (2016) 37, 2893–2962

11. 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

12. Complete AVN ablation + Pacemaker
Placement

13. 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.

14. • 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

15. • 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

16. • 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.

17. Advantages:
100% efficacy
85% symptomatic improvement
Eliminates need for rate control drugs
Disadvantages:
Pacemaker dependant
Need for anticoagulation
Good Candidates:
Tachy / Brady Syndrome
CHF -- BiV device
Medication refractory / intolerant
Elderly

18. 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, it 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.

19. AV Node Modification
• 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

20. 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.

21. • 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.

22. ablation
• 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 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).

23. 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.

24. 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

25. • 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.

26. • 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.

27. ABLATION
• MECHANISMS OF AF
• MULTIPLE WAVELET HYPOTHESIS( Moe etal):
• Constant formation of new wavelets occurs (wave break) resulting in multiple
wavelet fibrillation
• MOTHER ROTOR HYPOTHESIS(Jelife etal):
• AF is maintained by single stable rapid periodic source of excitation.
• Each wavefront arising from mother rotor faces different functional and
anatomical obstacles-wave break –multiple wavelet formation

28. Strategies for ablation:
• PULMONARY VEIN ISOLATION
• ABLATION OF CFAEs
• LINEAR ABLATION
• VOLTAGE MAP GUIDED ABLATION APPROACH
• ROTOR ABLATION
• OTHERS:
• Ganglionated plexuses(GPs)
• Non PV triggers-coronary sinus,ligament of marshall,and LAA

29. Pulmonary Vein Isolation:
• Hasguerre etal
• PV as the main source of ectopic beats initiating paroxysmal AF and showed that
complete isolation –isolated triggers from the substrate
• PVI alone effective in persistant AF and
• Wide antral isolation is more effective than ostial ablation
• Localization of the site of origin is guided by the endocardial activation time
• Single procedure success in not very high
• Efficacy improved by contact force sensing catheter (SMART-AF trial)
• Freedom from arrhythmia recurrence at 12 months –significantly high-81% vs 66% for
patients in whom stable contact force was applied during RFA.

30. Pulmonary Vein Isolation:
• 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

31. Pulmonary Vein Isolation
• 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.

32. 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

33. CFAEs
• Thought to represent continuous reentry of fibrillation waves into
restricted area or overlap of different wavelets entering the same area at
different times
• Proposed by Nadamanee etal and targeted for ablation
Single procedure success rate 63% at 12 months that improved to 77% with
repeat procedures
PITFALLS:
extensive amount of ablation is needed as it is not easy to differentiate
between culprit from bystander CFAEs during procedure

34. CFAE
• Defined as:
1. atrial electrograms that
are fractionated and
have 2 or more
deflections over a 10
second recording
period.
2. atrial electrograms
with a very short cycle
length(<120ms).

35. Linear ablation
• Addition to PVI it may improve success rates
• Roof line /mitral isthmus line/anterior line
• These lines compartmentalize the atria with the aim of preventing
macrorentrant circuits that are responsible to maintain AF
• ROOF and MITRAL ISTHMUS are the most commonly preferred sites
for substrate modification using linear ablation
• PITFALLS:
• It is a double edged sword
• Proarrythmic atrial tachycardia can be created secondary to incomplete
block line
• Some studies showed no further benefit (with PVI)
• SHOULD BE RESERVED FOR MACRORENTRANT AFL developed
after PVI during index or recurrent procedure.

36. Voltage map guided ablation approach
• Atrial structural remodeling –fibrosis and scarring –imp in AF
pathogenesis
• Scarring –correlates with reduced electrogram amplitudes recorded by
endocardial voltage maps
• Low voltage areas –extensively distributed in persistant AF c/c
paroxysmal AF
• These low voltage areas –cause arrhythmia recurrence after RFA
• Mostly located at—anterior ,septal and posterior LA walls
• Pts with additional voltage –based substrate modification had a
comparable 1 year outcome when compared with pts with normal
voltages undergoing PVI alone
• PITFALLS:
• Proarrthmia may develop from small channels or gaps created
• Unsuitable for massive atrial fibrosis

37. Rotor ablation (FIRM)
• FIRM-focal impulse and rotor modulation
• Narayan etal using 64 pole basket catheter
• Extended f/u of CONFIRM trial –showed rotors or focal sources seen in
97.7% of pts during AF
• After >2 yrs of f/u with 1.2 ablation procedures 78%maintained free of
AF
• PITFALLS:
1. FIRM map rotor is neither clearly defined nor identified
2. Rotor was identified in only a limited number(15%) of pts with
persistant AF

38. Ganglionated plexuses
• May contribute to AF by altering the refractory period of underlying
tissue and increasing the rate of depolarisation of certain triggers
• Ablation done through endocardial ablation of atria underlying the GP
thus ablating the atrial tissue as well
• Varied results
• Techniques are underinvestigation

39. Ganglionated plexuses

41. 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

45. 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.

46. • 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.

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
• 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)

53. 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
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)

54. FUTURE ABLATION TECHNIQUES
• TWO TOOLS ARE AVAILABLE
• 1. ROBOTIC MAGNETIC NAVIGATION SYSTEM:
• 2 permanent magnets are placed on either side of the patient(stereotaxis)
• 2. HANSEN NAVIGATION:
• remote navigation system that uses a robotically steerable sheath
• ROLE OF MR IMAGING TO IMAGE ATRIAL MYOCARDIAL SCAR has
been realized and its role in sustainance of AF in persistant fibrillates is
understood

55. 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.

56. • 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.
• 2strategies
• First strategy:
• WATCHMAN Device(FDA approved) and
• Amplatzer Cardiac Plug.

60. LAA CLOSURE DEVICES

61. • 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

62. WATCHMAN LAA Closure Device in situ
3000838-18

63. 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

64. • 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

65. • 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.

66. • 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.
• 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 indefinetely , 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.

67. • 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.

68. 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.

69. 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.

70. • 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.

71. • 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)

72. Conclusions:
• 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