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

Figures

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  Figure 1. Anatomical drawings of the heart relevant to AF ablation. This series of drawings shows the heart and associated relevant structures from four different perspectives relevant to AF ablation. This drawing includes the phrenic nerves and the esophagus. (A) The heart viewed from the anterior perspective. (B) The heart viewed from the right lateral perspective. (C) The heart viewed from the left lateral perspective. (D) The heart viewed from the posterior perspective. (E) The left atrium viewed from the posterior perspective. Illustration: Tim Phelps © 2017 Johns Hopkins University, AAM.

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  Figure 2. This figure includes six CT or MR images of the left atrium and pulmonary veins viewed from the posterior perspective. Common and uncommon variations in PV anatomy are shown. (A) Standard PV anatomy with 4 distinct PV ostia. (B) Variant PV anatomy with a right common and a left common PV. (C) Variant PV anatomy with a left common PV with a short trunk and an anomolous PV arising from the right posterior left atrial wall. (D) and (E) Variant PV anatomy with a common left PV with a long trunk. (F) Variant PV anatomy with a massive left common PV.

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  Figure 3. Schematic drawing showing various hypotheses and proposals concerning the mechanisms of atrial fibrillation. (A) Multiple wavelets hypothesis. (B) Rapidly discharging automatic foci. (C) Single reentrant circuit with fibrillatory conduction. (D) Functional reentry resulting from rotors or spiral waves. (E) AF maintenance resulting from dissociation between epicardial and endocardial layers, with mutual interaction producing multiplying activity that maintains the arrhythmia.

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  Figure 4. Structure and mechanisms of atrial fibrillation. (A) Schematic drawing of the left and right atria as viewed from the posterior perspective. The extension of muscular fibers onto the PVs can be appreciated. Shown in yellow are the five major left atrial autonomic ganglionic plexi (GP) and axons (superior left GP, inferior left GP, anterior right GP, inferior right GP, and ligament of Marshall). Shown in blue is the coronary sinus, which is enveloped by muscular fibers that have connections to the atria. Also shown in blue is the vein and ligament of Marshall, which travels from the coronary sinus to the region between the left superior PV and the left atrial appendage. (B) The large and small reentrant wavelets that play a role in initiating and sustaining AF. (C) The common locations of PV (red) and also the common sites of origin of non-PV triggers (shown in green). (D) Composite of the anatomic and arrhythmic mechanisms of AF. Adapted with permission from Calkins et al. Heart Rhythm 2012; 9:632–696.e21.2

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  Figure 5. Schematic drawing showing mechanisms of atrial flutter and atrial tachycardia. (A) Isthmus-dependent reverse common (clockwise) atrial flutter. (B) Isthmus-dependent common (counter clockwise) atrial flutter. (C) Focal atrial tachycardia with circumferential spread of activation of the atria (can arise from multiple sites within the left and right atrium). (D) Microreentrant atrial tachycardia with circumferential spread of activation of the atria. (E) Perimitral atrial flutter. (F) Roof-dependent atrial flutter.

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  Figure 6. Schematic of common lesion sets employed in AF ablation. (A) The circumferential ablation lesions that are created in a circumferential fashion around the right and the left PVs. The primary endpoint of this ablation strategy is the electrical isolation of the PV musculature. (B) Some of the most common sites of linear ablation lesions. These include a “roof line” connecting the lesions encircling the left and/or right PVs, a “mitral isthmus” line connecting the mitral valve and the lesion encircling the left PVs at the end of the left inferior PV, and an anterior linear lesion connecting either the “roof line” or the left or right circumferential lesion to the mitral annulus anteriorly. A linear lesion created at the cavotricuspid isthmus is also shown. This lesion is generally placed in patients who have experienced cavotricuspid isthmus-dependent atrial flutter clinically or have it induced during EP testing. (C) Similar to 6B, but also shows additional linear ablation lesions between the superior and inferior PVs resulting in a figure of eight lesion sets as well as a posterior inferior line allowing for electrical isolation of the posterior left atrial wall. An encircling…

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  Figure 7. Indications for catheter ablation of symptomatic atrial fibrillation. Shown in this figure are the indications for catheter ablation of symptomatic paroxysmal, persistent, and long-standing persistent AF. The Class for each indication based on whether ablation is performed after failure of antiarrhythmic drug therapy or as first-line therapy is shown. Please refer to Table 2B and the text for the indications for catheter ablation of asymptomatic AF.

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  Figure 8. Indications for surgical ablation of atrial fibrillation. Shown in this figure are the indications for surgical ablation of paroxysmal, persistent, and long-standing persistent AF. The Class for each indication based on whether ablation is performed after failure of antiarrhythmic drug therapy or as first-line therapy is shown. The indications for surgical AF ablation are divided into whether the AF ablation procedure is performed concomitantly with an open surgical procedure (such as mitral valve replacement), a closed surgical procedure (such as coronary artery bypass graft surgery), or as a stand-alone surgical AF ablation procedure performed solely for treatment of atrial fibrillation.

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  Figure 9. Schematic drawing showing catheter ablation of atrial fibrillation using either RF energy or cryoballoon AF ablation. (A) Shows a typical wide area lesion set created using RF energy. Ablation lesions are delivered in a figure of eight pattern around the left and right PV veins. Also shown is a linear cavotricuspid isthmus lesion created for ablation of typical atrial flutter in a patient with a prior history of typical atrial flutter or inducible isthmus-dependent typical atrial flutter at the time of ablation. A multielectrode circular mapping catheter is positioned in the left inferior PV. (B) Shows an ablation procedure using the cryoballoon system. Ablation lesions have been created surrounding the right PVs, and the cryoballoon ablation catheter is positioned in the left superior PV. A through the lumen multielectrode circular mapping catheter is positioned in the left superior PV. Illustration: Tim Phelps © 2017 Johns Hopkins University, AAM.