ESC Congress FA eBook 2016 - 8

FEATURED ARTICLE

(1%-2%), pulmonary vein stenosis (< 1%), persistent phrenic
nerve palsy (1%-2%), and vascular complications (2%-4%).
Catheter ablation is recommended after failed drug therapy
and in some instances as first-line therapy (Table 7).
After failed rhythm control attempts, additional treatment options should be carefully evaluated and discussed with the patient based on recommendations of
an AF Heart Team (see below). Options include another
AAD, repeat catheter ablation, hybrid therapy (AAD plus
ablation) surgical ablation (including thoracoscopy), or
reversion to a rate control approach.
APPROACH TO AF SURGERY

Manuel Castella, MD, PhD, University of Barcelona,
Barcelona, Spain, discussed the ESC recommended
approach to surgery for AF. Prof Castella emphasized
the importance of the AF Heart Team for AF surgery
decision-making to advise and inform patient choice

and to balance the benefits and risks of surgery. The AF
Heart Team should review decisions on complex patients,
including those involving AF surgery or extensive AF ablation, and be composed of cardiologists with expertise in
AAD therapy as well as experienced interventional electrophysiologists and cardiac surgeons.
Concomitant AF surgery is performed in patients
with AF already undergoing open-heart surgery. A systematic review produced for the guidelines, found that
performing concomitant AF surgery was associated
with increased freedom from AF, atrial flutter, and atrial
tachycardia compared with no concomitant AF surgery,
but with no impact on other clinical outcomes [Huffman
MD et al. Cochrane Database Syst Rev. 2016]. AF surgery
involves making several lesions in the atria to form scar
tissue, creating a maze of passages through which the
sinoatrial node impulse travels while preventing fibrillation waves from conducting. This is typically performed

Table 6. Recommendations for Long-Term Rhythm Control With Antiarrhythmic Drugs
Recommendations

Class

Level

The choice of AAD should be carefully evaluated, taking into account the presence of comorbidities, cardiovascular risk,
and potential for serious proarrhythmia, extracardiac toxic effects, patient preferences, and symptom burden.

Dronedarone, flecainide, propafenone, or sotalol are recommended for prevention of recurrent symptomatic AF in
patients with normal left ventricular function and without pathological left ventricular hypertrophy..

Dronedarone is recommended for prevention of recurrent symptomatic AF in patients with stable coronary artery
disease and without HF.

Amiodarone is recommended for prevention of recurrent symptomatic AF in patients with HF.

IIa

Amiodarone is more effective in preventing AF recurrences than other AADs, but extracardiac toxic effects are common
and increase with time. For this reason, other AADs should be considered first.
AAD, antiarrhythmic drug; AF, atrial fibrillation; HF, heart failure.

Reprinted from Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016. doi:10.1093/eurheartj/ehw210. By
permission of Oxford University Press on behalf of the European Society of Cardiology.

Table 7. Recommendations for Catheter Ablation
Recommendations

Class

Level

Ablation of common atrial flutter should be considered to prevent recurrent flutter as part of an AF ablation procedure if
flutter has been documented or occurs during AF ablation.

IIa

Catheter ablation of AF should be considered as first-line therapy to prevent recurrent AF and to improve symptoms in
selected patients with symptomatic paroxysmal AF as an alternative to antiarrhythmic drug therapy, considering patient
choice, benefit, and risk.

IIa

Catheter ablation or surgical ablation should be considered in patients with symptomatic persistent or long-standing
persistent AF refractory to antiarrhythmic drug therapy to improve symptoms, considering patient choice, benefit, and
risk, supported by an AF Heart Team.

IIa

Catheter ablation of symptomatic paroxysmal AF is recommended to improve AF symptoms in patients who have
symptomatic recurrences of AF on antiarrhythmic drug therapy (amiodarone, dronedarone, flecainide, propafenone,
sotalol) and who prefer further rhythm control therapy, when performed by an electrophysiologist who has received
appropriate training and is performing the procedure in an experienced center.

AF, atrial fibrillation.
Adapted from Kirchhof P et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016. doi:10.1093/eurheartj/ehw210. By
permission of Oxford University Press on behalf of the European Society of Cardiology.

October 2016

medicom-publishers.com/mcr

http://www.medicom-publishers.com/mcr

Table of Contents for the Digital Edition of ESC Congress FA eBook 2016