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

Title	2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation
Authors	Hugh Calkins, Gerhard Hindricks, Riccardo Cappato, Young-Hoon Kim, Eduardo B. Saad, Luis Aguinaga, Joseph G. Akar, Vinay Badhwar, Josep Brugada, John Camm, Peng-Sheng Chen, Shih-Ann Chen, Mina K. Chung, Jens Cosedis Nielsen, Anne B. Curtis, D. Wyn Davies, John D. Day, Andr d Avila, N.M.S. (Natasja) de Groot, Luigi Di Biase, Mattias Duytschaever, James R. Edgerton, Kenneth A. Ellenbogen, Patrick T. Ellinor, Sabine Ernst, Guilherme Fenelon, Edward P. Gerstenfeld, David E. Haines, Michel Haissaguer
Magazine	Heart rhythm
Date	05/12/2017
DOI	10.1016/j.hrthm.2017.05.012
Introduction	Catheter and surgical ablation of atrial fibrillation (AF) have significantly advanced over the past three decades, transitioning from investigational procedures to established treatment options for patients. Surgical ablation, including standard, minimally invasive, and hybrid approaches, is globally available in major hospitals, while catheter ablation of AF is even more widespread and is currently the most frequently performed catheter ablation procedure. This 2017 Consensus Statement represents a collaborative effort by the Heart Rhythm Society (HRS), European Heart Rhythm Association (EHRA), European Cardiac Arrhythmia Society (ECAS), Asia Pacific Heart Rhythm Society (APHRS), and Latin American Society of Cardiac Stimulation and Electrophysiology (SOLAECE). It updates prior consensus documents from 2007 and 2012, reflecting numerous advancements in AF ablation tools, techniques, and outcomes, driven by intensive research into AF mechanisms and treatments. The statement's primary aim is to offer a thorough review of AF catheter and surgical ablation, defining indications, techniques, and expected outcomes. It also provides recommendations for designing clinical trials in AF ablation and standardising outcome reporting, including relevant definitions. A writing group of 60 experts from 11 organisations contributed to this document. Recommendations were systematically balloted and approved by at least 80% of the members, following a public comment period. The grading system for evidence levels aligns with those used by the ACC and AHA, categorising recommendations from Class I (benefits markedly exceed risks, procedure should be performed) to Class III (no proven benefit, not recommended), and evidence levels from A (high-quality randomised trials/meta-analyses) to C-EO (expert opinion). While not a clinical guideline, this consensus document focuses specifically on AF ablation. It summarises the writing group's expert opinions, based on extensive literature review and clinical experience, to provide a foundational knowledge base for healthcare professionals caring for AF patients, particularly those undergoing or considering ablation, and those involved in AF ablation research. The ultimate clinical judgement for patient care remains with the healthcare provider and patient. AF is a prevalent supraventricular arrhythmia characterised by rapid, irregular atrial activation without distinct P waves on an electrocardiogram (ECG), lasting at least 30 seconds. This document adopts the AF classification system from the 2014 AHA/ACC/HRS Guideline, defining paroxysmal, persistent, long-standing persistent, and a new term, early persistent AF. The term 'permanent AF' is re-emphasised as a therapeutic attitude, not a pathophysiological attribute, and is not relevant in a rhythm control strategy. Silent AF refers to asymptomatic AF. Patient categorisation should reflect the most frequent AF pattern over six months before ablation. The document discourages the use of 'lone AF' and 'chronic AF' due to variable definitions. AF is a common, age-related arrhythmia with a significant global impact, affecting over 33 million individuals worldwide. It is associated with a five-fold increased stroke risk, higher mortality, increased heart failure risk, and a link to dementia, alongside a wide range of symptoms that impair quality of life. Asymptomatic AF carries a similar or worse prognosis than symptomatic AF. AF also poses a substantial economic burden, accounting for numerous hospitalisations and deaths annually in the United States, with significant healthcare cost increases. While AF control with ablation has not yet shown a proven impact on morbidity and mortality beyond symptom reduction and quality of life improvement, ongoing large-scale randomised clinical trials aim to clarify whether maintaining sinus rhythm through ablation reduces these adverse outcomes compared to rate control or antiarrhythmic therapy. The primary indication for catheter ablation remains the reduction of patient symptoms and improvement in quality of life. Assessing the correlation between symptoms and AF is crucial before ablation. Asymptomatic AF is more frequent in men, older patients, and those with continuous persistent AF, and is often observed following ablation. Consequently, post-ablation success cannot be judged solely by symptom absence. A thorough understanding of cardiac anatomy, including the atria, coronary sinus, and pulmonary veins (PVs), is essential for AF ablation. PV anatomy is highly variable, with myocardial muscle fibres extending into the PVs, possessing unique ion channel and action potential properties that predispose them to arrhythmogenesis. These PVs can act as focal triggers or sites for reentrant arrhythmias, a process exacerbated by increased atrial pressure. Electrophysiological studies reveal ERP heterogeneity and anisotropic conduction in PVs, supporting their role as a substrate for reentry.
Quote	Hugh Calkins, Gerhard Hindricks and Riccardo Cappato et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017. Vol. 14(10):e275-e444. DOI: 10.1016/j.hrthm.2017.05.012
Element	Calcium (Ca) , Sodium (Na) , Potassium (K) , Oxygen (O) , Hydrogen (H)
Materials	Biomaterials
Topics	Biomedical Materials , Materials Modeling and Simulation
Industry	Medical Devices , Research & Laboratory , Pharmaceutical Industry

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