Atrial fibrillation catheter ablation: Difference between revisions

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| colspan="3" align="center" bgcolor="#ABCDEF" | Conduction
| colspan="3" align="center" bgcolor="#ABCDEF" | Conduction
|-
|-
| <small>Sinus rhythm</small> [[Image:Heart conduct sinus.gif|none|230px]]
| <small>Sinus rhythm</small> [[Image:Heart conduct sinus.gif|none|75px]]
| <small>Atrial fibrillation</small> [[Image:Heart conduct atrialfib.gif|none|230px]]  
| <small>Atrial fibrillation</small> [[Image:Heart conduct atrialfib.gif|none|100px]]  
|}
|}
{{Infobox_Disease |
{{Infobox_Disease |
   Name          = Atrial fibrillation |
   Name          = |
   Image          = SinusRhythmLabels.png |
   Image          =  |
   Caption        = The P waves, which represent depolarization of the atria, are irregular or absent during atrial fibrillation. |
   Caption        = |
   DiseasesDB    = 1065 |
   DiseasesDB    = 1065 |
   ICD10          = {{ICD10|I|48||i|30}} |
   ICD10          = {{ICD10|I|48||i|30}} |
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   OMIM          = |
   OMIM          = |
   MedlinePlus    = 000184 |
   MedlinePlus    = 000184 |
   eMedicineSubj  = med |
   eMedicineSubj  = |
   eMedicineTopic = 184 |
   eMedicineTopic = |
   eMedicine_mult = {{eMedicine2|emerg|46}} |  
   eMedicine_mult = |  
}}
}}
{{SI}}
{{Atrial fibrillation}}
{{WikiDoc Cardiology Network Infobox}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}};
{{CMG}}


'''Associate Editor-In-Chief:''' {{CZ}}
'''''Synonyms and related keywords:''''' AF, Afib, fib


{{Editor Join}}
==Overview==
 
'''Synonyms and related keywords''': AF, Afib, fib
 
==Invasive treatment of atrial fibrillation==
====Radiofrequency ablation====
====Radiofrequency ablation====
In patients with AF where rate control drugs are ineffective and it is not possible to restore sinus rhythm using cardioversion, non-pharmacological alternatives are available. For example, to control rate it is possible to destroy the bundle of cells connecting the upper and lower chambers of the heart - the [[atrioventricular node]] - which regulates heart rate, and to implant a [[artificial pacemaker|pacemaker]] instead. A more complex technique, which avoids the need for a pacemaker, involves ablating groups of cells near the pulmonary veins where atrial fibrillation is thought to originate, or creating more extensive lesions in an attempt to prevent atrial fibrillation from establishing itself.<ref name="pmid16908781"/>
In patients with AF where rate control drugs are ineffective and it is not possible to restore sinus rhythm using cardioversion, non-pharmacological alternatives are available. For example, to control rate it is possible to destroy the bundle of cells connecting the upper and lower chambers of the heart - the [[atrioventricular node]] - which regulates heart rate, and to implant a [[artificial pacemaker|pacemaker]] instead. A more complex technique, which avoids the need for a pacemaker, involves ablating groups of cells near the pulmonary veins where atrial fibrillation is thought to originate, or creating more extensive lesions in an attempt to prevent atrial fibrillation from establishing itself.<ref name="pmid16908781"/>
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Efficacy and risks of catheter ablation of atrial fibrillation are areas of active debate.  A worldwide survey of the outcomes of 8745 ablation procedures<ref>{{cite journal | author=Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. | title=Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation | journal=Circulation | year=2005 | volume=111 | pages=1100–1105| pmid=15723973 | doi=10.1161/01.CIR.0000157153.30978.67}}</ref> demonstrated a 52% success rate (ranging from 14.5% to 76.5% among centers), with an additional 23.9% of patients becoming asymptomatic with addition of an antiarrhythmic medication.  In 27.3% of patients, more than one procedure was required to attain these results.  There was at least one major complication in 6% of patients.  A thorough discussion of results of catheter ablation was published in 2007<ref>{{cite journal | author=Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. | title=HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation | journal=Heart Rhythm | year=2007 | volume=4 | issue=6 | pages= 816–61 | pmid=17556213}}</ref>; it notes that results are widely variable, due in part to differences in technique, follow-up, definitions of success, use of antiarrhythmic therapy, and in experience and technical proficiency.
Efficacy and risks of catheter ablation of atrial fibrillation are areas of active debate.  A worldwide survey of the outcomes of 8745 ablation procedures<ref>{{cite journal | author=Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. | title=Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation | journal=Circulation | year=2005 | volume=111 | pages=1100–1105| pmid=15723973 | doi=10.1161/01.CIR.0000157153.30978.67}}</ref> demonstrated a 52% success rate (ranging from 14.5% to 76.5% among centers), with an additional 23.9% of patients becoming asymptomatic with addition of an antiarrhythmic medication.  In 27.3% of patients, more than one procedure was required to attain these results.  There was at least one major complication in 6% of patients.  A thorough discussion of results of catheter ablation was published in 2007<ref>{{cite journal | author=Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. | title=HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation | journal=Heart Rhythm | year=2007 | volume=4 | issue=6 | pages= 816–61 | pmid=17556213}}</ref>; it notes that results are widely variable, due in part to differences in technique, follow-up, definitions of success, use of antiarrhythmic therapy, and in experience and technical proficiency.


==See Also==
==Vote on and Suggest Revisions to the Current Guidelines==
* [[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation | The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
* [[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation | The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
==Guideline Resources==
*[http://content.onlinejacc.org/cgi/reprint/48/4/e149.pdf ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>
*[http://circ.ahajournals.org/content/123/10/e269.full.pdf 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>
*[http://circ.ahajournals.org/content/117/8/1101.full.pdf ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter] <ref name="pmid18283199">Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=18283199 ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society.] ''Circulation'' 117 (8):1101-20. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.187192 DOI:10.1161/CIRCULATIONAHA.107.187192] PMID: [http://pubmed.gov/18283199 18283199]</ref>


==References==
==References==
{{reflist|2}}
{{reflist|2}}
==Further Readings==
{{refbegin|2}}
* Fuster V, Rydén LE, Cannom DS, et al (2006). "ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation 114 (7): e257-354. doi:10.1161/CIRCULATIONAHA.106.177292. PMID 16908781.
* Estes NAM 3rd, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS, McNamara RL, Messer JV, Ritchie JL, Romeo SJW, Waldo AL, Wyse DG. ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with non valvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Performance Measures for Atrial Fibrillation). Circulation 2008; 117:1101–1120
{{refend}}
{{Electrocardiography}}
{{Circulatory system pathology}}
{{SIB}}


[[Category:Electrophysiology]]
[[Category:Electrophysiology]]

Revision as of 18:31, 30 October 2011

Conduction
Sinus rhythm
Atrial fibrillation
'
ICD-10 I48
ICD-9 427.31
DiseasesDB 1065
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Atrial Fibrillation Microchapters

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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];

Synonyms and related keywords: AF, Afib, fib

Overview

Radiofrequency ablation

In patients with AF where rate control drugs are ineffective and it is not possible to restore sinus rhythm using cardioversion, non-pharmacological alternatives are available. For example, to control rate it is possible to destroy the bundle of cells connecting the upper and lower chambers of the heart - the atrioventricular node - which regulates heart rate, and to implant a pacemaker instead. A more complex technique, which avoids the need for a pacemaker, involves ablating groups of cells near the pulmonary veins where atrial fibrillation is thought to originate, or creating more extensive lesions in an attempt to prevent atrial fibrillation from establishing itself.[1]

Ablation is a newer technique and has shown some promise for cases of recurrent AF that are unresponsive to conventional treatments. Radiofrequency ablation (RFA) uses radiofrequency energy to destroy abnormal electrical pathways in heart tissue. The energy emitting probe (electrode) is placed into the heart through a catheter inserted into veins in the groin or neck. Electrodes that can detect electrical activity from inside the heart are also inserted, and the electrophysiologist uses these to "map" an area of the heart in order to locate the abnormal electrical activity before eliminating the responsible tissue.

Most AF ablations consist of isolating the electrical pathways from the pulmonary veins (PV)[2], which are located on the posterior wall of the left atrium. All other veins from the body (including neck and groin) lead to the right atrium, so in order to get to the left atrium the catheters must get across the atrial septum. This is done by piercing a small hole in the septal wall. This is called a transseptal approach. Once in the left atrium, the physician may perform Wide Area Circumferential Ablation (WACA) to electrically isolate the PVs from the left atrium.[3]

Some more recent approaches to ablating AF is to target sites that are particularly disorganized in both atria as well as in the coronary sinus (CS). These sites are termed complex fractionated atrial electrogram (CFAE) sites.[4]. It is believed by some that the CFAE sites are the cause of AF, or a combination of the PVs and CFAE sites are to blame. New techniques include the use of cryoablation (tissue freezing using a coolant which flows through the catheter), microwave ablation, where tissue is ablated by the microwave energy "cooking" the adjacent tissue, and high intensity focused ultrasound (HIFU), which destroys tissue by heating. This is an area of active research, especially with respect to the RF ablation technique and emphasis on isolating the pulmonary veins that enter into the left atrium.

Efficacy and risks of catheter ablation of atrial fibrillation are areas of active debate. A worldwide survey of the outcomes of 8745 ablation procedures[5] demonstrated a 52% success rate (ranging from 14.5% to 76.5% among centers), with an additional 23.9% of patients becoming asymptomatic with addition of an antiarrhythmic medication. In 27.3% of patients, more than one procedure was required to attain these results. There was at least one major complication in 6% of patients. A thorough discussion of results of catheter ablation was published in 2007[6]; it notes that results are widely variable, due in part to differences in technique, follow-up, definitions of success, use of antiarrhythmic therapy, and in experience and technical proficiency.

Vote on and Suggest Revisions to the Current Guidelines

Guideline Resources

References

  1. ↑ 1.0 1.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines 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 European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
  2. ↑ The Cleveland Clinic
  3. ↑ Medscape
  4. ↑ Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, Khunnawat C, Ngarmukos T. (2004). "A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate". J Am Coll Cardiol. 43 (11): 2044–53. doi:10.1016/j.jacc.2003.12.054. PMID 15172410.
  5. ↑ Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. (2005). "Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation". Circulation. 111: 1100–1105. doi:10.1161/01.CIR.0000157153.30978.67. PMID 15723973.
  6. ↑ Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. (2007). "HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation". Heart Rhythm. 4 (6): 816–61. PMID 17556213.
  7. ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
  8. ↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199

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