Feature: Top 5 takeaways for AF ablation professionals

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Hugh G. Calkins, MD, offered this advice for physicians and hospital administrators who are too busy to read all 86 pages of the 2012 international consensus statement on catheter and surgical ablation of atrial fibrillation (AF): If nothing else, be aware of five important changes.

“This is a complete rewrite from start to finish,” said Calkins, co-author of the consensus statement and director of cardiac arrhythmia services and the electrophysiology laboratory at Johns Hopkins Hospital in Baltimore, in an interview. “It is a complete overhaul of the document because in every area there have been significant changes.”

The consensus statement, recently published in Heart Rhythm, was jointly written by 45 members of Heart Rhythm Society, the European Heart Rhythm Association and the European Cardiac Arrhythmia Society in collaboration with the American College of Cardiology (ACC), the American Heart Association (AHA), the Asia Pacific Heart Rhythm Society and the Society of Thoracic Surgeons. The 2012 version follows the inaugural statement published in 2007 and includes guidance on patient selection, management and follow-up as well as an update on techniques, definitions and clinical trial design.

The document is rich in detail for electrophysiologists, surgeons and administrators seeking information on a particular subject, but Calkins listed five overarching topics of interest to all professionals.

  • Indications: The authors added areas of indications and class levels of evidence for catheter and surgical ablation using a system adopted by the ACC and AHA. Indications are presented with a class and grade, consistent with guidelines, along with a ranking of the level of evidence based on the committee’s review.
  • Anticoagulation management: The experts noted a trend toward performing procedures in patients who are continuously anticoagulated with warfarin rather than switching to low molecular weight or intravenous heparin before and after the procedure. “It has been largely adopted in many places, but not all,” Calkins said.
  • Anticoagulation management, post-procedure: Calkins pointed out that the experts reiterated that all patients should be anticoagulated for two months after the procedure. A decision to stop anticoagulation at two months should be based on stroke risk and not on the perceived presence or absence of AF. “We say that if someone has a high risk for stroke, even if you think the procedure was successful, the standard of care is to continue anticoagulation,” he said. “To stop anticoagulation is not an appropriate indication for AF ablation in the asymptomatic patient.”
  • Standardization:  Previous studies on the safety and efficacy of AF ablation have used a variety of definitions and end points, making it difficult to understand and compare findings. The authors offered a uniform set of definitions of the types of AF and complications as well as other standards that they recommended researchers apply in trials. “It is an encyclopedia of new definitions that will help move the field forward in terms of standardizing reporting strategies, study designs, etc.,” Calkins said.
  • Broad representation: Calkins emphasized that the 45 experts who contributed to the consensus statement represented thought leaders from around the globe. He said the consensus reflects their collective knowledge and highlights best practices.

Other topics in the statement include AF mechanisms; the rationale for AF ablation; techniques; technologies and tools; anesthesia and esophageal monitoring; follow-up issues; outcomes and efficacy; complications; training requirements and competencies; and surgical AF.

Additionally, the writers acknowledged the use of new anticoagulation agents such as the thrombin inhibitor dabigatran (Pradaxa, Boehringer Ingelheim) or the factor Xa inhibitors rivaroxaban (Xarelto, Janssen Research & Development) and apixaban (Eliquis, Bristol-Myers Squibb/Pfizer) but added that to date clinical experience with these strategies is limited.

They concluded that the statement was an up-to-date review of indications, techniques and outcomes but given the evolving nature of catheter and surgical ablation of AF, another revision will be warranted in the future.

“The field has come a long way but we tried to point out the gaps, strengths and limitations,” Calkins said. “The goal is to improve the outcomes of our patients.” The consensus statement is available here.

The May issue of Cardiovascular