Atrial fibrillation catheter ablation
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Anahita Deylamsalehi, M.D.[3] Vendhan Ramanujam M.B.B.S [4] Laith Adnan Allaham, M.D.[5]
Overview
Catheter ablation is an established and evolving therapy for atrial fibrillation (AF) that has undergone a major paradigm shift. The 2023 ACC/AHA/ACCP/HRS Guideline elevated catheter ablation to a Class I (strong) recommendation as first-line therapy in selected patients with symptomatic paroxysmal AF.[1][2] Pulmonary vein isolation (PVI) remains the cornerstone ablation strategy. Three energy modalities are currently in clinical use: radiofrequency (RF), cryoballoon, and pulsed field ablation (PFA). PFA represents a transformative nonthermal technology that preferentially ablates myocardium while sparing adjacent structures like the esophagus and phrenic nerve.[3]
Indications for Catheter Ablation
The decision to pursue catheter ablation relies heavily on patient symptoms, AF classification, heart failure status, and prior response to antiarrhythmic drugs (AADs).
2023 ACC/AHA/ACCP/HRS Guideline Recommendations
The 2023 US guidelines establish the current framework for AF ablation, notably upgrading first-line ablation for paroxysmal AF from Class IIa to Class I.[1]
| Class I |
| "1. In patients with symptomatic AF in whom AADs have been ineffective, contraindicated, not tolerated, or not preferred, and continued rhythm control is desired, catheter ablation is useful to improve symptoms. (Level of Evidence: A)" |
| "2. In selected patients (generally younger with few comorbidities) with symptomatic paroxysmal AF in whom rhythm control is desired, catheter ablation is useful as first-line therapy to improve symptoms and reduce progression to persistent AF. (Level of Evidence: A)" |
| "3. In patients with symptomatic or clinically significant atrial flutter, catheter ablation is useful for improving symptoms. (Level of Evidence: A)" |
| Class IIa |
| "1. In patients undergoing ablation for AF, ablation of additional clinically significant supraventricular arrhythmias can be useful to reduce the likelihood of future arrhythmia. (Level of Evidence: B-NR)" |
| "2. In patients (other than younger with few comorbidities) with symptomatic paroxysmal or persistent AF managed with a rhythm-control strategy, catheter ablation as first-line therapy can be useful to improve symptoms. (Level of Evidence: B-R)" |
| Class IIb |
| "1. In selected patients with asymptomatic or minimally symptomatic AF, catheter ablation may be useful for reducing progression of AF and its associated complications. (Level of Evidence: B-NR)" |
The following recommendation is derived from Section 9.2 (Management of AF in Patients With Heart Failure) of the 2023 Guidelines:[1]
| Class I |
| "1. In selected patients with symptomatic AF and HF with reduced ejection fraction (HFrEF), catheter ablation is recommended to improve symptoms, reduce HF hospitalizations, and improve survival. (Level of Evidence: A)" |
Cross-Guideline Comparison
The indications for catheter ablation contain nuanced differences across international societies, particularly regarding persistent AF and HFrEF. The following table highlights the comparative approaches between the 2024 ESC/EACTS, 2023 ACC/AHA, and 2024 CCS guidelines.[4]
| Topic | 2024 ESC/EACTS | 2023 ACC/AHA/ACCP/HRS | 2024 CCS |
|---|---|---|---|
| After failed AAD | Paroxysmal and persistent AF: Class I, LOE: A | Symptomatic AF with desired rhythm control, AAD ineffective/not preferred: Class I, LOE: A | Recommended in symptomatic AF who remain symptomatic after AAD trial |
| First-line: Paroxysmal AF | Class I, LOE: A | Class I, LOE: A | First-line in selected symptomatic patients |
| First-line: Persistent AF | Class IIb, LOE: C | Class IIa, LOE: B-R | Not separately specified |
| AF-related tachymyopathy | Class I, LOE: B | Class I, LOE: A | — |
| HFrEF (without clear tachymyopathy) | Class IIa, LOE: B | Class I, LOE: A | — |
| Ablation technique | PVI is cornerstone; optimal strategy beyond PVI not clarified | PVI recommended as primary lesion set; value of endpoints beyond PVI uncertain (Class IIb, LOE: B) | PVI is cornerstone |
Catheter Ablation in Heart Failure
Catheter ablation in HFrEF represents a major paradigm shift. The 2023 ACC/AHA Guideline upgrade to a Class I indication was driven by robust trial data demonstrating mortality and hospitalization benefits:[1]
- CASTLE-AF: In AF patients with HFrEF (LVEF ≤35%), ablation reduced all-cause mortality by 47% and hospitalization for worsening HF by 44% compared with medical therapy.
- AATAC: In 203 patients with persistent AF, LVEF <40%, and NYHA class II–III HF, catheter ablation achieved 70% freedom from AF vs. 34% with amiodarone (P < 0.001), with a 45% relative risk reduction in unplanned hospitalization (31% vs. 57%; P < 0.001) and mortality of 8% vs. 18% (P = 0.037).[5]
- CABANA HF subgroup: Among 778 patients with NYHA class ≥II HF, ablation produced a 36% relative reduction in the primary composite endpoint (HR 0.64; 95% CI 0.41–0.99) and a 43% relative reduction in all-cause mortality (HR 0.57; 95% CI 0.33–0.96) compared with drug therapy. Notably, ~79% of these patients had preserved EF (>50%).[6]
- CASTLE-HTx: In 194 patients with AF and end-stage HF referred for transplantation evaluation, ablation reduced the composite of death, LVAD implantation, or urgent transplantation from 30% to 8% (HR 0.24; 95% CI 0.11–0.52; P < 0.001). All-cause mortality was 6% vs. 20% (HR 0.29; 95% CI 0.12–0.72). The trial was stopped early for efficacy.[7]
Ablation Techniques and Energy Modalities
Pulmonary Vein Isolation (PVI)
PVI is the cornerstone of all AF ablation procedures. The goal is complete electrical isolation of all pulmonary veins. According to the 2024 EHRA/HRS Expert Consensus and the 2025 HRS Policy Statement, anatomic circumferential ablation with any energy modality is necessary but not sufficient alone. Complete electrical isolation (demonstrating entrance and exit block) must be confirmed by electrophysiologic testing.[8][9]
- Ablation must target the PV antrum (wide-area circumferential ablation) rather than within the PV ostia to minimize the risk of PV stenosis.
- Comprehensive EP testing (including programmed stimulation) remains essential during AF ablation to identify and treat non-PV triggers and additional arrhythmia mechanisms.
- Cavotricuspid isthmus ablation is recommended in patients with documented or inducible typical atrial flutter.
Radiofrequency Ablation (RF)
RF ablation utilizes thermal energy delivered via irrigated-tip catheters to create point-by-point lesions. Modern contact-force sensing catheters and ablation index tools have significantly improved lesion quality and durability. RF offers flexible lesion creation for non-PV targets.
Cryoballoon Ablation
Cryoballoon ablation uses a balloon catheter advanced to the PV ostium, utilizing liquid nitrous oxide to create circumferential cryothermal lesions.
- Efficacy is comparable to RF ablation for PVI. The FIRE AND ICE trial (762 patients) demonstrated noninferiority of cryoballoon to RF ablation (1-year event rates 34.6% vs. 35.9%; HR 0.96; 95% CI 0.76–1.22; P < 0.001 for noninferiority), with shorter procedure times.[10]
- The EARLY-AF and STOP AF First trials, which established first-line ablation as a Class I recommendation, both used cryoballoon technology.[11]
- It carries a higher rate of phrenic nerve injury (~1.5–3%) compared with RF (<0.5%), though usually transient.
Pulsed Field Ablation (PFA)
PFA is a largely nonthermal modality using microsecond-scale, high-voltage electrical fields to cause irreversible electroporation and selective myocardial cell death. It represents a major technological advance due to its tissue selectivity.[3]
- Efficacy: The ADVENT (pentaspline) and AdmIRE (variable-loop) trials demonstrated noninferiority to thermal ablation for paroxysmal AF, with superior procedural efficiency. Four-year data from ADVENT-LTO shows preserved effectiveness and fewer repeat ablations than thermal modalities.
- Safety: Safety: PFA dramatically reduces risks of atrioesophageal fistula, phrenic nerve paralysis, and PV stenosis compared with thermal ablation. However, PFA introduces unique safety considerations: (a) coronary artery spasm (~0.1%), mitigated by prophylactic nitroglycerin when ablating near coronary arteries; (b) dose-dependent hemolysis, which is subclinical in most patients but rarely causes acute kidney injury requiring dialysis (~0.02%), particularly in patients with preexisting renal impairment; and (c) a potential signal for rare unexplained sudden cardiac arrest (0.019%). These data derive from the MANIFEST-US registry of 41,968 PFA procedures.[12]
Periprocedural Anticoagulation
The 2023 ACC/AHA Guideline and 2024 EHRA Consensus provide the following recommendations for periprocedural anticoagulation:[1][8]
- Pre-procedural: Ablation should be performed on uninterrupted therapeutic anticoagulation. Direct oral anticoagulants (DOACs) are preferred over uninterrupted warfarin in eligible patients due to lower major bleeding risks. Uninterrupted or minimally interrupted DOAC strategies are Class I recommendations.[13] Transesophageal echocardiography (TEE) is mandatory to rule out LA thrombus in patients with AF duration ≥48 hours or unknown duration who have not been therapeutically anticoagulated.
- Intraprocedural: Intravenous heparin is required prior to or immediately following transseptal puncture, targeting an activated clotting time (ACT) ≥300 seconds.
- Post-procedural: Oral anticoagulation must be continued for at least 3 months post-ablation. Beyond 3 months, discontinuation has traditionally not been recommended in high-risk patients per the 2023 ACC/AHA guideline. However, emerging RCT evidence (ALONE-AF, JAMA 2025; OCEAN, NEJM 2025) suggests that in patients without documented AF recurrence ≥12 months after ablation and moderate stroke risk (mean CHA₂DS₂-VASc ~2), OAC discontinuation does not increase thromboembolic events and significantly reduces major bleeding. A 2026 meta-analysis of 3 RCTs (2,324 patients) confirmed these findings. These data may inform future guideline revisions, but current guidelines still recommend continuing OAC based on stroke risk factors.[14][15][16]
Efficacy and Outcomes
- Ablation vs. Antiarrhythmic Drugs: In the CABANA trial, ablation reduced AF recurrence by 48% compared to AADs over 5 years. The primary composite endpoint (death, disabling stroke, serious bleeding, cardiac arrest) was not significantly reduced by intention-to-treat (HR 0.86; 95% CI 0.65–1.15; P = 0.30; 8.0% vs. 9.2%), affected by 27.5% crossover from the drug to ablation arm. However, the secondary endpoint of death or cardiovascular hospitalization was significantly reduced (HR 0.83; 95% CI 0.74–0.93; P = 0.001).[17]
- First-Line Therapy: The EARLY-AF and STOP AF First trials demonstrated that first-line cryoablation significantly reduced recurrent atrial arrhythmias compared to initial AAD therapy. Extended 3-year EARLY-AF data showed a 75% relative reduction in progression to persistent AF (HR 0.25; 95% CI 0.09–0.70; 1.9% vs. 7.4%).[18]
- Repeat Procedures: Catheter ablation is not always curative; PV reconnection is common. Approximately 17–27% of patients undergo repeat ablation. Ablation is best viewed as a strategy to reduce AF burden.
Complications
Procedure-related complication rates are ~4.5% overall (2013–2022), with severe complications in ~2.4%.[19] In the contemporary period (2018–2022), rates have declined significantly to 3.77% overall and 1.87% severe (P = 0.043 for temporal trend). Complications are more frequent with low-volume operators (<25 cases/year) and hospitals (<50 cases/year).
| Complication | Frequency | Timing | Key Features |
|---|---|---|---|
| Vascular access complications | 1–7% | Periprocedural | Hematoma, AV fistula, pseudoaneurysm. |
| Cardiac tamponade | 0.4–1.5% | During procedure | Hypotension and shock; treated urgently with pericardiocentesis. |
| Stroke / TIA | 0.1–1.0% | Periprocedural to 1 week | Neurologic deficits; risk mitigated by strict anticoagulation. |
| Pulmonary vein stenosis | 0.1–0.8% | Months post-procedure | Dyspnea, hemoptysis; diagnosed by CT/MRI. Near-eliminated with PFA. |
| Phrenic nerve paralysis | 0.2–0.4% | During procedure | Dyspnea; more common with cryoballoon (~1.5–3%). Near-eliminated with PFA. |
| Atrioesophageal fistula | ~0.2% | 1–4 weeks | Chest pain, fever, neurologic symptoms; highly lethal; diagnosed by CT. Endoscopy is contraindicated. Near-eliminated with PFA. |
| Pneumonia | 0.4–1.0% | Days | Cough, fever. |
| Death | 0.1–0.4% | Periprocedural | Usually results from cardiac tamponade, stroke, or atrioesophageal fistula. |
Post-Ablation Management
- Blanking Period: The first 90 days post-ablation is considered a blanking period. Early recurrences of atrial arrhythmias are common secondary to tissue inflammation and do not necessarily predict long-term procedural failure.
- Short-Term AADs: Short-term use of AADs during the blanking period can be considered to reduce early recurrences; necessity should be reassessed at 3 months.
- Monitoring: Ambulatory ECG monitoring is recommended to assess for recurrence, particularly when evaluating long-term rhythm control success.
- Risk Factor Modification: Optimization of modifiable risk factors — including weight loss, alcohol reduction, treatment of obstructive sleep apnea, and blood pressure control — significantly improves ablation outcomes and reduces AF recurrence. This is a Class I recommendation in the 2023 ACC/AHA guideline.[1]
High-Yield Clinical Pearls and Common Pitfalls
- Pearl: PVI is the only proven ablation lesion set. Ablation targets beyond PVI remain of uncertain value and should not be routinely performed.
- Pearl: PFA offers distinct safety advantages by largely sparing the esophagus, phrenic nerve, and PV tissue due to targeted electroporation.
- Pitfall: Discontinuing anticoagulation after ablation remains a nuanced decision. The 2023 ACC/AHA guideline recommends continuing OAC based on CHA₂DS₂-VASc score regardless of ablation success. However, recent RCTs (ALONE-AF, OCEAN) suggest that in carefully selected patients without AF recurrence for ≥12 months and moderate stroke risk, OAC discontinuation may be safe. Until guidelines are updated, shared decision-making incorporating individual stroke and bleeding risk is essential.[14][15]
- Pitfall: Delaying ablation until multiple AADs have failed. Guidelines strongly support first-line ablation in appropriately selected candidates to prevent disease progression.
- Pitfall: Overlooking an atrioesophageal fistula. Patients presenting 1–4 weeks post-ablation with fever, chest pain, dysphagia, or neurologic symptoms require urgent CT imaging. Esophagogastroduodenoscopy (EGD) risks fatal air embolism and is strictly contraindicated.
2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society[20]
Recommendation for Catheter Ablation in HF Referenced studies that support the new recommendation are summarized in Online Data Supplement 7
| Class IIb |
| 1. AF catheter ablation may be reasonable in selected patients with symptomatic AF and HF with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower mortality rate and reduce hospitalization for HF.S6.3.4-1,S6.3.4-2NEW: New evidence, including data on improved mortality rate, has been published for AF catheter ablation compared with medical therapy in patients with HF. (Level of Evidence: B-R) |
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)[21]
Rhythm Control
AF catheter ablation to Maintain Sinus Rhythm
| 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 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)" |
| 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)" |
| 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)" |
Sources
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation[21]
2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation[20]
2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation[22]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR (January 2024). "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 149 (1): e1–e156. doi:10.1161/CIR.0000000000001193. PMID 38033089 Check
|pmid=value (help). - ↑ Wiggins BS, Cibotti-Sun M, Moore MM (January 2024). "2023 Atrial Fibrillation Guideline-at-a-Glance". J Am Coll Cardiol. 83 (1): 280–284. doi:10.1016/j.jacc.2023.10.021. PMID 38043044 Check
|pmid=value (help). - ↑ 3.0 3.1 Reddy VY, Gerstenfeld EP, Natale A, Whang W, Cuoco FA, Patel C, Mountantonakis SE, Gibson DN, Harding JD, Ellis CR, Ellenbogen KA, DeLurgio DB, Osorio J, Achyutha AB, Schneider CW, Mugglin AS, Albrecht EM, Stein KM, Lehmann JW, Mansour M (November 2023). "Pulsed Field or Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation". N Engl J Med. 389 (18): 1660–1671. doi:10.1056/NEJMoa2307291. PMID 37634148 Check
|pmid=value (help). - ↑ Wolfes J, Ellermann C, Frommeyer G, Eckardt L (April 2025). "Comparison of the Latest ESC, ACC/AHA/ACCP/HRS, and CCS Guidelines on the Management of Atrial Fibrillation". JACC Clin Electrophysiol. 11 (4): 836–849. doi:10.1016/j.jacep.2024.12.018. PMID 39985521 Check
|pmid=value (help). - ↑ Di Biase L, Mohanty P, Mohanty S, Santangeli P, Trivedi C, Lakkireddy D, Reddy M, Jais P, Themistoclakis S, Dello Russo A, Casella M, Pelargonio G, Narducci ML, Schweikert R, Neuzil P, Sanchez J, Horton R, Beheiry S, Hongo R, Hao S, Rossillo A, Forleo G, Tondo C, Burkhardt JD, Haissaguerre M, Natale A (April 2016). "Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device: Results From the AATAC Multicenter Randomized Trial". Circulation. 133 (17): 1637–1644. doi:10.1161/CIRCULATIONAHA.115.019406. PMID 27029350.
- ↑ Packer DL, Piccini JP, Monahan KH, Al-Khalidi HR, Silverstein AP, Noseworthy PA, Poole JE, Bahnson TD, Lee KL, Mark DB (April 2021). "Ablation Versus Drug Therapy for Atrial Fibrillation in Heart Failure: Results From the CABANA Trial". Circulation. 143 (14): 1377–1390. doi:10.1161/CIRCULATIONAHA.120.050991. PMID 33554614 Check
|pmid=value (help). - ↑ Sohns C, Fox H, Marrouche NF, Crijns H, Costard-Jaeckle A, Bergau L, Hindricks G, Dagres N, Sossalla S, Schramm R, Fink T, El Hamriti M, Moersdorf M, Sciacca V, Konietschke F, Rudolph V, Gummert J, Tijssen J, Sommer P (October 2023). "Catheter Ablation in End-Stage Heart Failure with Atrial Fibrillation". N Engl J Med. 389 (15): 1380–1389. doi:10.1056/NEJMoa2306037. PMID 37634135 Check
|pmid=value (help). Vancouver style error: initials (help) - ↑ 8.0 8.1 Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY (September 2024). "2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation". Heart Rhythm. 21 (9): e31–e149. doi:10.1016/j.hrthm.2024.03.017. PMID 38597857 Check
|pmid=value (help). - ↑ Liu CF, Berman AE, Chung MK, Dukes J, Ellenbogen KA, Greenberg SJ, Hadziabdulahovic S, Kanagasundram AN, Larsen TR, Mainigi SK, Sachdev M, Schoenfeld MH, Slotwiner DJ, Thosani A, Weiss JP, Miller L, Smith AM, Shanker AJ (January 2025). "HRS policy statement on catheter ablation of atrial fibrillation". Heart Rhythm. 22 (1): 289–292. doi:10.1016/j.hrthm.2024.09.048. PMID 39326511 Check
|pmid=value (help). - ↑ Kuck KH, Brugada J, Fürnkranz A, Metzner A, Ouyang F, Chun KR, Elvan A, Arentz T, Bestehorn K, Pocock SJ, Albenque JP, Tondo C (June 2016). "Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation". N Engl J Med. 374 (23): 2235–2245. doi:10.1056/NEJMoa1602014. PMID 27042964.
- ↑ Andrade JG, Wells GA, Deyell MW, Bennett M, Essebag V, Champagne J, Roux JF, Yung D, Skanes A, Khaykin Y, Morillo C, Jolly U, Novak P, Lockwood E, Amit G, Angaran P, Sapp J, Wardell S, Lauck S, Macle L, Verma A (January 2021). "Cryoablation or Drug Therapy for Initial Treatment of Atrial Fibrillation". N Engl J Med. 384 (4): 305–315. doi:10.1056/NEJMoa2029980. PMID 33197159 Check
|pmid=value (help). - ↑ Turagam MK, Aryana A, Day JD, Dukkipati SR, Hounshell T, Nair D, Natale A, Weiner S, Cheung JW, Chinitz L, Cuoco F, Daccarett M, Dandamudi S, Gambhir A, Gandhavadi M, Kim J, Metzl MD, Mikaelian B, Peress D, Romero JE, Sanchez J, Sandler DA, Shaik NA, Shehata M, Siddique SM, Singh A, Singleton MJ, Sundaram S, Vivas Y, Waks JW, Yamamura KH, Zipse M, Reddy VY (January 2026). "Multicenter Study on the Safety of Pulsed Field Ablation in Over 40,000 Patients: MANIFEST-US". J Am Coll Cardiol. 87 (2): 172–193. doi:10.1016/j.jacc.2025.10.051. PMID 41389071 Check
|pmid=value (help). - ↑ Di Biase L, Lakkireddy DJ, Marazzato J, Velasco A, Diaz JC, Navara R, Chrispin J, Rajagopalan B, Natale A, Mohanty S, Zhang X, Della Rocca D, Dalal A, Park K, Wiley J, Batchelor W, Cheung JW, Dangas G, Mehran R, Romero J (January 2024). "Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review". J Am Coll Cardiol. 83 (1): 82–108. doi:10.1016/j.jacc.2023.09.831. PMID 38171713 Check
|pmid=value (help). - ↑ 14.0 14.1 Kim D, Shim J, Choi EK, Oh IY, Kim J, Lee YS, Park J, Ko JS, Park KM, Sung JH, Park HW, Park HS, Kim JY, Kang KW, Kim D, Park JK, Kim DH, Kim JB, Yu HT, Kim TH, Uhm JS, Pak HN, Joung B (October 2025). "Long-Term Anticoagulation Discontinuation After Catheter Ablation for Atrial Fibrillation: The ALONE-AF Randomized Clinical Trial". JAMA. 334 (14): 1246–1254. doi:10.1001/jama.2025.14679. PMID 40886309 Check
|pmid=value (help). - ↑ 15.0 15.1 Verma A, Birnie DH, Jiang C, Heidbüchel H, Hindricks G, Kirchhof P, Healey JS, Wang Y, Dagres N, Deyell MW, Sanders P, Pathak RK, Koopman P, Nuyens D, Novak P, Amit G, Dussault C, Makanjee B, Quinn FR, Jolly U, Iden L, Kuniss M, Sharma M, Ha A, Essebag V, Champagne J, Hill MD, Smith EE, Wells GA (January 2026). "Antithrombotic Therapy after Successful Catheter Ablation for Atrial Fibrillation". N Engl J Med. 394 (4): 323–332. doi:10.1056/NEJMoa2509688. PMID 41211931 Check
|pmid=value (help). - ↑ Kaisaier W, Chen Y, Dong Y, He J, Liu T, Liu C, Zhu W (July 2026). "Discontinuation of Oral Anticoagulation After Successful Catheter Ablation for Atrial Fibrillation: Meta-Analysis of Randomized Clinical Trials". Thromb Haemost. doi:10.1055/a-2906-7109. PMID 42398953 Check
|pmid=value (help). - ↑ Packer DL, Mark DB, Robb RA, Monahan KH, Bahnson TD, Poole JE, Noseworthy PA, Rosenberg YD, Jeffries N, Mitchell LB, Flaker GC, Pokushalov E, Romanov A, Bunch TJ, Noelker G, Ardashev A, Revishvili A, Wilber DJ, Cappato R, Kuck KH, Hindricks G, Davies DW, Kowey PR, Naccarelli GV, Reiffel JA, Piccini JP, Silverstein AP, Al-Khalidi HR, Lee KL (April 2019). "Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial". JAMA. 321 (13): 1261–1274. doi:10.1001/jama.2019.0693. PMID 30874766.
- ↑ Andrade JG, Deyell MW, Macle L, Wells GA, Bennett M, Essebag V, Champagne J, Roux JF, Yung D, Skanes A, Khaykin Y, Morillo C, Jolly U, Novak P, Lockwood E, Amit G, Angaran P, Sapp J, Wardell S, Lauck S, Cadrin-Tourigny J, Kochhäuser S, Verma A (January 2023). "Progression of Atrial Fibrillation after Cryoablation or Drug Therapy". N Engl J Med. 388 (2): 105–116. doi:10.1056/NEJMoa2212540. PMID 36342178 Check
|pmid=value (help). - ↑ Benali K, Khairy P, Hammache N, Petzl A, Da Costa A, Verma A, Andrade JG, Macle L (May 2023). "Procedure-Related Complications of Catheter Ablation for Atrial Fibrillation". J Am Coll Cardiol. 81 (21): 2089–2099. doi:10.1016/j.jacc.2023.03.418. PMID 37225362 Check
|pmid=value (help). - ↑ 20.0 20.1 January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC; et al. (2019). "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons". Circulation. 140 (2): e125–e151. doi:10.1161/CIR.0000000000000665. PMID 30686041.
- ↑ 21.0 21.1 January, C. T.; Wann, L. S.; Alpert, J. S.; Calkins, H.; Cleveland, J. C.; Cigarroa, J. E.; Conti, J. B.; Ellinor, P. T.; Ezekowitz, M. D.; Field, M. E.; Murray, K. T.; Sacco, R. L.; Stevenson, W. G.; Tchou, P. J.; Tracy, C. M.; Yancy, C. W. (2014). "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". Circulation. doi:10.1161/CIR.0000000000000041. ISSN 0009-7322.
- ↑ Joglar, J. A.; Chung, M. K.; Armbruster, A. L.; Benjamin, E. J.; Chyou, J. Y.; Cronin, E. M.; Deswal, A.; Eckhardt, L. L.; Goldberger, Z. D.; Gopinathannair, R.; Gorenek, B.; Hess, P. L.; Hlatky, M.; Hogan, G.; Huang, H. D.; Indik, J. H. (2024). "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Journal of the American College of Cardiology. 83 (1): 109–279. doi:10.1016/j.jacc.2023.08.017. PMID 38043043 Check
|pmid=value (help).