N. M. S. de Groot

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

During the past three decades, catheter and surgical ablation of atrial fibrillation (AF) have evolved from investigational procedures to their current role as effective treatment options for patients with AF. Surgical ablation of AF, using either standard, minimally invasive, or hybrid techniques, is available in most major hospitals throughout the world. Catheter ablation of AF is even more widely available, and is now the most commonly performed catheter ablation procedure. n nIn 2007, an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA), and the European Cardiac Arrhythmia Society (ECAS).1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC). This Consensus Statement on Catheter and Surgical AF Ablation was rewritten in 2012 to reflect the many advances in AF ablation that had occurred in the interim.2 The rate of advancement in the tools, techniques, and outcomes of AF ablation continue to increase as enormous research efforts are focused on the mechanisms, outcomes, and treatment of AF. For this reason, the HRS initiated an effort to rewrite and update this Consensus Statement. Reflecting both the worldwide importance of AF, as well as the worldwide performance of AF ablation, this document is the result of a joint partnership between the HRS, EHRA, ECAS, the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia [SOLAECE]). The purpose of this 2017 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a writing group, convened by these five international societies. The writing group is charged with defining the indications, techniques, and outcomes of AF ablation procedures. Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes, including definitions relevant to this topic. n nThe writing group is composed of 60 experts representing 11 organizations: HRS, EHRA, ECAS, APHRS, SOLAECE, STS, ACC, American Heart Association (AHA), Canadian Heart Rhythm Society (CHRS), Japanese Heart Rhythm Society (JHRS), and Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardiacas [SOBRAC]). All the members of the writing group, as well as peer reviewers of the document, have provided disclosure statements for all relationships that might be perceived as real or potential conflicts of interest. All author and peer reviewer disclosure information is provided in Appendix A and Appendix B. n nIn writing a consensus document, it is recognized that consensus does not mean that there was complete agreement among all the writing group members. Surveys of the entire writing group were used to identify areas of consensus concerning performance of AF ablation procedures and to develop recommendations concerning the indications for catheter and surgical AF ablation. These recommendations were systematically balloted by the 60 writing group members and were approved by a minimum of 80% of these members. The recommendations were also subject to a 1-month public comment period. Each partnering and collaborating organization then officially reviewed, commented on, edited, and endorsed the final document and recommendations. n nThe grading system for indication of class of evidence level was adapted based on that used by the ACC and the AHA.3,4 It is important to state, however, that this document is not a guideline. The indications for catheter and surgical ablation of AF, as well as recommendations for procedure performance, are presented with a Class and Level of Evidence (LOE) to be consistent with what the reader is familiar with seeing in guideline statements. A Class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks, and that AF ablation should be performed; a Class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks, and that it is reasonable to perform AF ablation; a Class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks, and that AF ablation may be considered; and a Class III recommendation means that AF ablation is of no proven benefit and is not recommended. n nThe writing group reviewed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from high-quality evidence from more than one randomized clinical trial, meta-analyses of high-quality randomized clinical trials, or one or more randomized clinical trials corroborated by high-quality registry studies. The writing group ranked available evidence as Level B-R when there was moderate-quality evidence from one or more randomized clinical trials, or meta-analyses of moderate-quality randomized clinical trials. Level B-NR was used to denote moderate-quality evidence from one or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies. This designation was also used to denote moderate-quality evidence from meta-analyses of such studies. Evidence was ranked as Level C-LD when the primary source of the recommendation was randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological or mechanistic studies of human subjects. Level C-EO was defined as expert opinion based on the clinical experience of the writing group. n nDespite a large number of authors, the participation of several societies and professional organizations, and the attempts of the group to reflect the current knowledge in the field adequately, this document is not intended as a guideline. Rather, the group would like to refer to the current guidelines on AF management for the purpose of guiding overall AF management strategies.5,6 This consensus document is specifically focused on catheter and surgical ablation of AF, and summarizes the opinion of the writing group members based on an extensive literature review as well as their own experience. It is directed to all health care professionals who are involved in the care of patients with AF, particularly those who are caring for patients who are undergoing, or are being considered for, catheter or surgical ablation procedures for AF, and those involved in research in the field of AF ablation. This statement is not intended to recommend or promote catheter or surgical ablation of AF. Rather, the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient. n nThe main objective of this document is to improve patient care by providing a foundation of knowledge for those involved with catheter ablation of AF. A second major objective is to provide recommendations for designing clinical trials and reporting outcomes of clinical trials of AF ablation. It is recognized that this field continues to evolve rapidly. As this document was being prepared, further clinical trials of catheter and surgical ablation of AF were under way.

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

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 & André 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 Haissaguerre & Robert H. Helm & Elaine Hylek & Warren M. Jackman & Jose Jalife & Jonathan M. Kalman & Josef Kautzner &Hans Kottkamp &Karl Heinz Kuck &Koichiro Kumagai &Richard Lee & Thorsten Lewalter & Bruce D. Lindsay & Laurent Macle & Moussa Mansour & Francis E. Marchlinski & Gregory F. Michaud & Hiroshi Nakagawa & Andrea Natale & Stanley Nattel & Ken Okumura & Douglas Packer & Evgeny Pokushalov & Matthew R. Reynolds & Prashanthan Sanders & Mauricio Scanavacca & Richard Schilling &Claudio Tondo &Hsuan-Ming Tsao &Atul Verma &David J.Wilber & Teiichi Yamane

Atrial fibrillation: to map or not to map?

Isolation of the pulmonary veins may be an effective treatment modality for eliminating atrial fibrillation (AF) episodes but unfortunately not for all patients. When ablative therapy fails, it is assumed that AF has progressed from a trigger-driven to a substrate-mediated arrhythmia. The effect of radiofrequency ablation on persistent AF can be attributed to various mechanisms, including elimination of the trigger, modification of the arrhythmogenic substrate, interruption of crucial pathways of conduction, atrial debulking, or atrial denervation. This review discusses the possible effects of pulmonary vein isolation on the fibrillatory process and the necessity of cardiac mapping in order to comprehend the mechanisms of AF in the individual patient and to select the optimal treatment modality.

The future of atrial fibrillation therapy: intervention on heat shock proteins influencing electropathology is the next in line

Atrial fibrillation (AF) is the most common age-related cardiac arrhythmia accounting for one-third of hospitalisations. Treatment of AF is difficult, which is rooted in the progressive nature of electrical and structural remodelling, called electropathology, which makes the atria more vulnerable for AF. Importantly, structural damage of the myocardium is already present when AF is diagnosed for the first time. Currently, no effective therapy is known that can resolve this damage.Previously, we observed that exhaustion of cardioprotective heat shock proteins (HSPs) contributes to structural damage in AF patients. Also, boosting of HSPs, by the heat shock factor-1 activator geranylgeranylacetone, halted AF initiation and progression in experimental cardiomyocyte and dog models for AF. However, it is still unclear whether induction of HSPs also prolongs the arrhythmia-free interval after, for example, cardioversion of AF.In this review, we discuss the role of HSPs in the pathophysiology of AF and give an outline of the HALT&REVERSE project, initiated by the HALT&REVERSE Consortium and the AF Innovation Platform. This project will elucidate whether HSPs (1) reverse cardiomyocyte electropathology and thereby halt AF initiation and progression and (2) represent novel biomarkers that predict the outcome of AF conversion and/or occurrence of post-surgery AF.

Multimodality imaging for patient evaluation and guidance of catheter ablation for atrial fibrillation — Current status and future perspective

Left atrial catheter ablation is an established non-pharmacological therapy for the treatment of atrial fibrillation. The importance of a noninvasive multimodality imaging approach is emphasized by the current guidelines for the various phases of the ablation work-up e.g. patient identification, therapy guidance and procedural evaluation. Advances in the capabilities of imaging modalities and the increasing cost of healthcare warrant a review of the multimodality approach. This review discusses the application of cardiac imaging for pulmonary vein and left atrial ablation divided into stages: pre-procedural stage (assessment of left atrial dimensions, left atrial appendage thrombus and pulmonary vein anatomy), peri-procedural stage (integration of anatomical and electrical information) and post-procedural stage (evaluation of efficacy by assessment of tissue properties). Each section is dedicated to one of the subtopics of a stage, allowing a thorough comparison to be made between the strengths and weaknesses of the different imaging modalities and the identification of one that exhibits the potential for a single technique approach.

Unexpected finding in an adult with ventricular fibrillation and an accessory pathway: non-compaction cardiomyopathy

IntroductionIn this report, we demonstrate a patient presenting with anout-of-hospital cardiac arrest due to ventricular fibrillation(VF). At the hospital the presence of an accessory path-way could be seen on the surface electrocardiogram(ECG). Surprisingly, cardiac imaging also showed thepresence of isolated left ventricular non-compaction car-diomyopathy (INVM).INVMwasfirstdescribedin1984byEngberdingetal.as an unclassified cardiomyopathy [1]. It is assumed to bethe result of an arrest of the compaction process duringthe normal development of the heart (week 5–8). InINVM, the spaces within the intertrabeculated meshworkpersist with deep recesses and no other cardiac abnormal-ities [1, 2]. Clinical presentation of INVM includesheart failure, thromboembolic events and arrhythmias[1, 3, 5, 7]. Conduction abnormalities and arrhythmiasobserved in INVM patients are left or right bundlebranch block, supraventricular tachycardia and ventric-ular tachycardia [1–3, 5–10].However,thepresenceofanaccessorypathwayandINVMin one patient with VF has never been described before.Case reportA 19-year-old female presented to the emergency depart-ment after an out-of-hospital cardiac arrest due to VF.After alcohol consumption she jumped off a 1 m highpier into the water. While dressing she complained ofdizziness, palpitations and breathlessness. She collapsednear her car and lost consciousness. The paramedics ar-rived within 7 min and provided cardiopulmonary resus-citation. VF was documented on arrival (Fig. 1). Afterthree DC shocks sinus rhythm resumed and due to a lowGlasgow Coma Score she was intubated. At the intensivecardiac care unit therapeutichypothermia was induced for24 h. She regained consciousness without any signs ofpersistent neurological injury. Anamnestic there were noprevious palpitations or (near) collapses. The patient hadnoted that she was relatively quickly exhausted duringphysical exercise. Despite this, she played field hockeywithout any restraints. Her family history was negative forcardiovascular diseases, arrhythmias or sudden cardiacdeath. The 12-lead ECG after defibrillation showed pre-

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

Hugh Calkins, MD (Chair), Gerhard Hindricks, MD (Vice-Chair),* Riccardo Cappato, MD (Vice-Chair),3,{ Young-Hoon Kim, MD, PhD (Vice-Chair),4,x Eduardo B. Saad, MD, PhD (Vice-Chair), Luis Aguinaga, MD, PhD, Joseph G. Akar, MD, PhD, Vinay Badhwar, MD, Josep Brugada, MD, PhD,* John Camm, MD,* Peng-Sheng Chen, MD, Shih-Ann Chen, MD,12,x Mina K. Chung, MD, Jens Cosedis Nielsen, DMSc, PhD,* Anne B. Curtis, MD,15,k D. Wyn Davies, MD,16,{ John D. Day, MD, André d’Avila, MD, PhD, N.M.S. (Natasja) de Groot, MD, PhD,* Luigi Di Biase, MD, PhD,* Mattias Duytschaever, MD, PhD,* James R. Edgerton, MD, Kenneth A. Ellenbogen, MD, Patrick T. Ellinor, MD, PhD, Sabine Ernst, MD, PhD,* Guilherme Fenelon, MD, PhD, Edward P. Gerstenfeld, MS, MD, David E. Haines, MD, Michel Haissaguerre, MD,* Robert H. Helm, MD, Elaine Hylek, MD, MPH, Warren M. Jackman, MD, Jose Jalife, MD, Jonathan M. Kalman, MBBS, PhD,34,x Josef Kautzner, MD, PhD,* Hans Kottkamp, MD,* Karl Heinz Kuck, MD, PhD,* Koichiro Kumagai, MD, PhD,38,x Richard Lee, MD, MBA, Thorsten Lewalter, MD, PhD,40,{ Bruce D. Lindsay, MD, Laurent Macle, MD,** Moussa Mansour, MD, Francis E. Marchlinski, MD, Gregory F. Michaud, MD, Hiroshi Nakagawa, MD, PhD, Andrea Natale, MD, Stanley Nattel, MD, Ken Okumura, MD, PhD, Douglas Packer, MD, Evgeny Pokushalov, MD, PhD,* Matthew R. Reynolds, MD, MSc, Prashanthan Sanders, MBBS, PhD, Mauricio Scanavacca, MD, PhD, Richard Schilling, MD,* Claudio Tondo, MD, PhD,* Hsuan-Ming Tsao, MD,57,x Atul Verma, MD, David J. Wilber, MD, Teiichi Yamane, MD, PhD

Remote magnetic catheter navigation: more than just bells and whistles ?

Catheter ablation is nowadays an established treatment modality for both atrial and ventricular tachyarrhythmias. Manual navigation of the ablation catheter can be challenging in patients with a complex cardiac anatomy due to, for example, (surgically corrected or palliated) congenital heart defects, resulting in a long procedure time and excessive X-ray exposure. In the past decades, sophisticated mapping and ablation techniques have been developed in order to improve the outcome of ablative therapy. These technologies include remote navigation systems such as the magnetic navigation system (Stereotaxis Inc.) and the non-magnetic robotic navigation system (Sensei Hansen Medical). In this issue, Roudijk et al. report on the value of remote magnetic catheter navigation and ablation in children and young adult patients with and without congenital heart disease in their paper entitled: ‘Catheter ablation in children and young adults: is there an additional benefit from remote magnetic navigation [1]? In this elegant paper, the outcome of ablative therapy of a variety of tachyarrhythmias was examined.

Endovascular catheter ablation of ventricular tachycardia in a patient with a surgically repaired congenital left ventricular aneurysm.

We present a patient with a congenital left ventricular aneurysm who visited our outpatient clinic for a routine check-up and, during this visit, lost consciousness due to sustained ventricular tachycardia. In our patient, endocardial mapping revealed extensive conduction abnormalities, and successful ablation was accomplished at the endocardial surface.

Catheter ablation of right ventricular outflow tract tachycardia using contact force guidance

Outflow tract tachycardias (OTT) originating from the right or left ventricular outflow tract are thought to be benign. However, symptoms can be disabling and deterioration of left ventricular function may occur with a high arrhythmia burden. Catheter ablation has a high acute success rate of up to 90xa0%, but recurrences are not uncommon [1, 2]. Novel catheter designs, and mapping and ablation technologies aim to improve procedural outcome, lower the complication rate, and increase the long-term success rate [3]. The TactiCath® catheter (TactiCath®, Endosense, SA Meyrin/Geneva, Switzerland, distributed by Biotronik, Berlin, Germany) is a contact force (CF) sensing radiofrequency ablation catheter that provides real-time assessment of tip-to-tissue CF during ablation [4]. Until now, it has only been used in ablation of supraventricular tachycardias, mainly atrial fibrillation. In this report, we describe the case of a patient who underwent successful ablation of right ventricular OTT and ventricular premature beats (VPBs) using CF guidance. To the best of our knowledge, this is the first case ever described of OTT ablation using CF with the TactiCath® catheter.