the preferred tests in suspected cases [65]. A ventilation/perfusion lung scan can also be used to diagnose PV stenosis. Stent placement is a more effective therapy for PV stenosis compared with balloon angioplasty [69]. It is associated with a significant and almost immediate improvement in symptoms and pulmonary blood flow [62-64]. In series of patients who underwent balloon angioplasty with or without stenting, in-segment or in-stent stenosis requiring repeat intervention developed in approximately 50 percent of patients [63,64]. The roles of either elective stenting or surgery are not well defined [65]. However, the incidence of PV stenosis has significantly decreased due to improvement in ablative techniques, especially with moving the ablation lesions toward the atrial side of the PV-atrial junction. Periprocedural embolic events Patients undergoing CA to prevent recurrent AF are at risk for embolic events before, during, and after the procedure. The incidence of clinical stroke or transient ischemic attack is between 0 and 2 percent [9]. The role of anticoagulant therapy in this setting is discussed in detail separately. (See "Catheter ablation to prevent recurrent atrial fibrillation: Anticoagulation".) MRI-detected brain lesions and cognitive impairment Stroke and transient ischemic attack are not the only neurologic sequelae of CA. Multiple MRI studies performed within 24 hours https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 12/32 7/5/23, 8:10 AM Atrial fibrillation: Catheter ablation - UpToDate after RFA have demonstrated new cerebral lesions in 7 to 44 percent of asymptomatic patients [70-72]. However, in a study of 60 AF patients at relatively low risk for stroke who underwent CA, only one patient developed new asymptomatic lesions on MRI soon after the procedure [73]. These lesions were presumed secondary to microemboli [74]. Studies of the impact of these lesions on neurocognitive function have come to differing conclusions as to the significance of these lesions, as illustrated by the following studies: The prevalence of cognitive impairment after RFA was evaluated in a study of 150 patients: 60 undergoing ablation for paroxysmal AF, 30 for persistent AF, 30 for supraventricular tachycardia, and 30 matched AF patients awaiting RFA (the control group) [75]. All RFA patients received periprocedural enoxaparin, and most patients with AF had a CHADS 2 score of 0 or 1 ( table 3). All patients underwent eight neuropsychological tests at baseline and at 2 and 90 days after RFA. The prevalence of neurocognitive dysfunction at day 90 was 13, 20, 3, and 0 percent, respectively. In a study of 37 patients with paroxysmal AF who underwent 41 ablation procedures, MRI performed within 48 hours showed new brain lesions in 41 percent of patients and 44 percent of procedures [72]. Follow-up MRI at six months found glial scar in about 12 percent of those with lesions. However, there was no decline of neurocognitive function on testing. Vascular complications Vascular complications are among the most common adverse events related to AF ablation, likely due to the number and size of intravascular sheaths and the need for anticoagulation both during and immediately following the procedure. These complications include hematoma at the sites of catheter insertion, pseudoaneurysm, arteriovenous fistula, or retroperitoneal bleeding. Pseudoaneurysm and arteriovenous fistulae rates of 0.53 and 0.43 percent, respectively, have been reported [57,58]. This risk can be significantly reduced by the use of vascular ultrasound, which was demonstrated, in one study of 689 patients, to reduce the risk of vascular access complications from 5.3 to 1.1 percent [76]. Conservative management alone is usually sufficient for large hematomas and retroperitoneal bleeding, though anticoagulation may need to be held, and transfusion may be necessary in those patients where the risks of such interventions are warranted. Echo-guided manual compression and percutaneous intervention are usually effective treatments of femoral pseudoaneurysms or arteriovenous fistula, but direct surgical intervention is sometimes required [77]. Atrial esophageal fistula This is a potentially life-threatening medical emergency for which the exact mechanism is unknown. The overall incidence is 0.3 to 0.54 percent, and mortality is between 50 and 83 percent [78]. Early recognition can be missed due to the low awareness of https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 13/32 7/5/23, 8:10 AM Atrial fibrillation: Catheter ablation - UpToDate this rare complication. It is important for patients to be educated as to warning signs and to contact their AF ablation center should any suggestive symptoms develop. Clinical manifestations usually present one to four weeks post-ablation (range of 2 to 60 days), and the most common symptoms are fever, chest pain, and recurrent neurologic events from septic emboli. Chest computed tomography is the preferred diagnostic modality. Endoscopy with air insufflation should not be performed. Arrhythmic complications New reentrant circuits created by the ablation lesions can lead to atypical left atrial (LA) flutter. These circuits tend to develop around regions of LA scar and often involve the perimitral region. Due to anatomic variability and technical challenges, successful ablation is more difficult than that for typical right atrial flutter involving the isthmus of the inferior vena cava and tricuspid annulus. A significant percentage of LA flutter following PVI may also involve the musculature of the coronary sinus or the roof of the left atrium [79]. (See "Electrocardiographic and electrophysiologic features of atrial flutter".) Typical atrial flutter may also occur after LA ablation due to alterations in activation patterns of the LA and may have an unusual electrocardiographic morphology. LA flutter appears to be more common following circumferential (as opposed to segmental) PVI [49,79-82]. In a randomized comparison of circumferential and segmental PVI, LA flutter developed in 9 of the 50 patients undergoing circumferential PVI, and in 1 of the 50 patients in the segmental PVI group [49]. In addition, many of the recurrent LA arrhythmias following segmental PVI are focal atrial tachycardias, as opposed to macroreentrant flutter circuits, and are often successfully treated with repeat isolation of the PVs. Other Other complications with their respective incidences are summarized: Phrenic nerve injury (<1 percent) [57,58] in patients receiving RFA (and up to 6.3 percent in those receiving cryoablation). (See 'Comparison of radiofrequency and cryothermal ablation' above.) Periesophageal vagal injury (gastric hypomotility) [48,83]. Acute coronary artery occlusion/injury (<1 percent) [65,84]. Iatrogenic atrial septal defect after cryoballoon ablation without clinical consequence (20 percent) [85]. https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 14/32 7/5/23, 8:10 AM Atrial fibrillation: Catheter ablation - UpToDate PREVENTION OF RECURRENCE The following therapies have been evaluated for their ability to prevent late recurrent AF; only treatment of obstructive sleep apnea (OSA) seems to be beneficial: Glucocorticoid therapy We do not believe there is sufficient evidence to recommend the use of prophylactic glucocorticoid therapy. Two observations raise the possibility that corticosteroid therapy might be useful for the prevention of early recurrence. Firstly, inflammation is associated with the development of AF, and systemic and local inflammatory responses may result from radiofrequency ablation (RFA) [86] (see "Epidemiology, risk factors, and prevention of atrial fibrillation", section on 'Inflammation and infection'). Secondly, glucocorticoid prophylaxis reduces the risk of the development of perioperative AF in patients undergoing coronary artery bypass graft surgery. (See "Atrial fibrillation and flutter after cardiac surgery", section on 'Ineffective or possibly effective therapies'.) The possible benefit from prophylactic glucocorticoid therapy was evaluated in a study of 125 patients with paroxysmal AF who were randomly assigned to either three days of glucocorticoid therapy or placebo starting immediately after the procedure [87]. The rate of AF recurrence (primary endpoint) was significantly lower in the glucocorticoid group at one month (27 versus 49 percent), with most of the benefit occurring during the first three days (7 versus 31 percent). Treatment of OSA OSA is a predictor of recurrent AF after RFA. Patients with OSA who undergo CA should be encouraged to be evaluated for treatment with continuous positive airway pressure [88,89]. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults".) Colchicine Colchicine, another drug with antiinflammatory properties, has been shown to decrease the risk of postoperative AF after cardiac surgery, particularly in patients with post-pericardiotomy syndrome. However, pending additional studies showing benefit, we do not use prophylactic colchicine. (See "Post-cardiac injury syndromes", section on 'Prevention'.) The potential ability of colchicine to reduce the incidence of early recurrent AF after pulmonary vein isolation was evaluated in a study of 206 individuals with paroxysmal AF who were randomly assigned to colchicine 0.5 mg twice daily or placebo beginning on the day of CA and continuing for three months [90]. After follow-up of about 15 months, there https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 15/32 7/5/23, 8:10 AM Atrial fibrillation: Catheter ablation - UpToDate was a lower recurrence rate of AF in patients taking colchicine (31.1 versus 49.5 percent; odds ratio [OR] 0.46, 95% CI 0.26-0.81). Angiotensin inhibition The data are mixed as to whether angiotensin converting enzyme inhibitors/angiotensin II receptor blockers reduce AF after CA procedures. This issue is discussed elsewhere. (See "ACE inhibitors, angiotensin receptor blockers, and atrial fibrillation", section on 'Catheter ablation of atrial fibrillation'.) Periprocedural weight reduction Some studies suggest that periprocedural weight reduction may be a helpful adjunct to CA. Pre-procedure weight reduction In a retrospective study of 600 patients, weight reduction before CA was associated with reduced AF occurrence [91]. Freedom from AF was observed in 420 patients (70 percent) at 15 months. Percent weight loss during the year before CA independently predicted freedom from AF through the next 15 months (OR 1.17, 95% CI 1.11-1.23). Post-procedure weight reduction The SORT-AF Study compared one-year AF burden in patients with obesity participating in a weight loss program versus usual care after CA [92]. The intervention group had a small reduction in weight loss (5 versus 1 kg in controls). AF burden (measured with implantable loop recorder) after ablation did not differ between the two groups (OR 1.14, 95% CI 0.37-3.6). However, a reduction in body mass index was associated with a decrease in AF recurrence in persistent compared with paroxysmal AF patients. FOLLOW-UP Surveillance for recurrence of atrial arrhythmias is important in patients who have undergone CA. We agree with the joint Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society expert consensus statement of catheter and surgical ablation of AF [65], which recommends the following: First visit with electrophysiologist at a minimum of three months, and then every six months for at least two years. Electrocardiograms (ECGs) at all visits; symptomatic (eg, palpitations) patients should be evaluated with some form of event monitoring. The optimal method for screening for episodes of AF after ablation is not known. In the above studies, late recurrent AF was detected by patient symptoms, serial ECGs, 24- to 48-hour Holter https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 16/32 7/5/23, 8:10 AM Atrial fibrillation: Catheter ablation - UpToDate monitoring, and implantable cardiac monitor [10,16,93,94]. Rhythm transmitters were also used in the first few months [94]. With the exceptions of implantable cardiac monitor, preexisting dual-chamber pacemaker, or implantable cardioverter-defibrillator with AF detection capabilities, these methods may underestimate the incidence of recurrence due to sampling error [95]. In addition, as has been well demonstrated, patients with AF have a high rate of asymptomatic episodes. (See "Paroxysmal atrial fibrillation", section on 'Natural history' and 'Efficacy' above.) MANAGEMENT OF RECURRENCE Some patients with symptomatic AF after CA are candidates for a repeat procedure. The decision to do so is usually based on a patient's assessment of the potential benefit and risks. Other patients may choose a trial of antiarrhythmic drug therapy to reduce symptoms. The most common reason for recurrence of paroxysmal AF is reconnection of previously ablated electrically active tissue. Based upon the recurrence rates of AF after ablation, many patients are candidates for repeat ablation. We tell our patients that the success rate is in the range of 50 to 85 percent for a single procedure based primarily on AF type and anatomy, and that about 20 percent of patients have at least a second procedure. Success rates after a second procedure can be as high as 90 percent. Some experts and patients have agreed to repeat the procedure a third time. Patients with a history of persistent AF have a lower success rate and are less often felt to be good candidates for repeat procedures. The issue of whether patients with AF recurrence should undergo a repeat procedure or be placed on antiarrhythmic drug therapy was addressed in a study that randomly assigned 154 patients with symptomatic, paroxysmal AF recurrence to either repeat ablation or antiarrhythmic drugs [96]. During three-year follow-up, fewer patients in the repeat ablation group demonstrated AF progression, defined as an increase in AF burden >30 percent relative to baseline based on insertable cardiac monitor (also sometimes referred to as implantable cardiac monitor or implantable loop recorder) data or development of persistent AF (25 versus 79 percent; p<0.01). Despite limitations of this study, it supports our approach of offering a second ablation procedure to most patients. CONTRAINDICATIONS While there are few absolute contraindications, the risks and benefits of AF ablation should be carefully considered in each patient. https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 17/32 7/5/23, 8:10 AM Atrial fibrillation: Catheter ablation - UpToDate Contraindications to AF ablation include preexisting left atrial or left atrial appendage thrombus, inability to safely administer anticoagulation during or after the procedure, inability to tolerate sedation, patients with atrial septal defect closure devices in whom transseptal access cannot be performed, and those with interruption of the inferior vena cava. While not contraindicated, ablations performed on those with very long-standing persistent AF (ie, >2 years), severe mitral stenosis or regurgitation, or large left atria are expected to have lower success rates. (See 'Predictors of recurrence' above.) SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Atrial fibrillation" and "Society guideline links: Arrhythmias in adults".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Beyond the Basics topics (see "Patient education: Atrial fibrillation (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Role of catheter ablation (CA) CA for atrial fibrillation (AF) leads to symptom improvement in many patients. However, it has not convincingly been shown to decrease the risks of embolization (eg, stroke) or death. (See 'Efficacy' above.) https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 18/32 7/5/23, 8:10 AM Atrial fibrillation: Catheter ablation - UpToDate Efficacy Current techniques for CA should lead to one-year freedom from symptomatic AF while off antiarrhythmic drug therapy in about 75 to 90 percent of patients with drug- resistant paroxysmal AF and no significant structural heart disease. (See 'Efficacy' above.) Complications Important complications of CA include death, cardiac tamponade, stroke, vascular trauma, and phrenic nerve palsy ( table 1). Specific signs and symptoms can help identify complications ( table 2). (See 'Complications' above.) Recurrence For patients who have recurrent AF after a first ablation, there are two reasonable management strategies: a clinical trial of an antiarrhythmic agent or proceeding directly to a second ablation. Patients may have a preference for one or the other. (See 'Management of recurrence' above.) 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J Am Coll Cardiol 2005; 45:873. 96. Pokushalov E, Romanov A, De Melis M, et al. Progression of atrial fibrillation after a failed initial ablation procedure in patients with paroxysmal atrial fibrillation: a randomized comparison of drug therapy versus reablation. Circ Arrhythm Electrophysiol 2013; 6:754. https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 26/32 7/5/23, 8:10 AM Atrial fibrillation: Catheter ablation - UpToDate Topic 949 Version 66.0 https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 27/32 7/5/23, 8:10 AM Atrial fibrillation: Catheter ablation - UpToDate GRAPHICS Signs and symptoms of complications of catheter ablation to prevent atrial fibrillation within a month post-ablation Sign/symptom Differential Suggested evaluation