The n e w e ng l a n d j o u r na l of
clinical therapeutics
From the Cleveland Clinic, Cleveland. Ad-
dress reprint requests to Dr. Saliba at the
Center for Atrial Fibrillation, Cleveland
Clinic, 9500 Euclid Ave., Desk J2-2, Cleve-
land, OH 44195, or at salibaw@ccf.org.
N Engl J Med 2011;365:2296-304.
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m e dic i n e
Catheter Ablation for Atrial Fibrillation
Oussama Wazni, M.D., Bruce Wilkoff, M.D., and Walid Saliba, M.D.
This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion
of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies,
the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines,
if they exist, are presented. The article ends with the authors’ clinical recommendations.
A 59-year-old man with hypertension and diabetes presents with palpitations, fatigue,
and shortness of breath and is found to be in atrial fibrillation. He has had recurring
episodes of atrial fibrillation over the previous 5 years, typically with similar symp-
toms, and has received warfarin for stroke prevention. He has required direct-current
cardioversion to restore sinus rhythm on two occasions despite treatment with fle-
cainide and subsequently with dofetilide. The use of amiodarone resulted in hyper-
thyroidism. After undergoing cardioversion, he is referred to a cardiac electrophysi-
ologist, who recommends catheter ablation.
The Cl inic a l Probl em
Atrial fibrillation affects up to 5 million people in the United States, and data sug-
gest that as the population ages, the incidence will continue to increase.1,2 The rate
of ischemic stroke among patients with nonvalvular atrial fibrillation averages 5%
per year.3 The rate of death among patients with atrial fibrillation is about double that
among patients with normal sinus rhythm.3 The overall cost of treating recurrent
atrial fibrillation has been estimated to be more than $6.5 billion per year.4
Atrial fibrillation is usually a progressive disease. The natural history often begins
with infrequent episodes of limited duration termed paroxysmal atrial fibrillation
(often defined as episodes that terminate spontaneously within 1 week). Such epi-
sodes then tend to become more frequent and longer in duration, progressing to
persistent atrial fibrillation (which fails to terminate spontaneously within 7 days
and may require cardioversion) or permanent atrial fibrillation (if the arrhythmia
lasts for more than 1 year and cardioversion either has not been attempted or has
failed). Symptoms include palpitations, shortness of breath, and fatigue; particularly
for symptomatic patients, atrial fibrillation has adverse effects on quality of life.3
PATHOPH YSIOL O GY A ND EFFEC T OF THER A PY
The electrophysiological basis of atrial fibrillation requires both a trigger that initi-
ates the dysrhythmia and a substrate that can sustain it.5,6 The most common trig-
gers of atrial fibrillation are ectopic atrial beats that arise from the muscle sleeves
of the pulmonary veins.7,8 These triggers may be provoked by the intrinsic activity
of cardiac ganglionic plexuses, which are clustered in the vicinity of the pulmonary
vein–left atrial junction.9,10 The pulmonary vein–left atrial junction and an enlarged
atrium harboring fibrosis and inflammation serve as the substrate for sustaining
wavelets of atrial fibrillation. With persistence of atrial fibrillation, a further elec-
trophysiological change in the atria — namely, shortening of the refractory period
n engl j med 365;24  nejm.org  december 15, 2011
The New England Journal of Medicine
 clinical ther apeutics

Figure 1. Catheter Placement during Atrial Fibrillation

Ablation and Conduction Block of Pulmonary-Vein Trig-
gers by Means of Ablation.
Panel A shows how all catheters are advanced through
the femoral veins to the right atrium. The intracardiac
echocardiographic (ICE) catheter is positioned to allow
imaging of the procedure. The ablation catheter and cir-
cular mapping catheter are advanced across the inter-
atrial septum with the use of a specialized needle. Panel
B shows a computed tomographic scan of the posterior
wall of the left atrium and the pulmonary veins. Trigger-
ing ectopic atrial beats (yellow) arising in the pulmonary
veins propagate (blue) toward the atrium but are blocked
from entering the atrium by ablation lesions (red). LIPV
denotes left inferior pulmonary vein, LSPV left superior
pulmonary vein, RIPV right inferior pulmonary vein, and
RSPV right superior pulmonary vein.

of the atrial muscle — occurs and predisposes to

the development of other triggers and wavelets.
This process results in perpetuation of atrial fi-
brillation and in a greater predisposition to atrial
fibrillation. Maintenance of sinus rhythm can re-
verse these changes and mechanisms. Hence,
atrial fibrillation begets atrial fibrillation, and
sinus rhythm begets sinus rhythm.11-13
Atrial fibrillation ablation is a therapeutic
technique that uses radiofrequency energy or
freezing to destroy atrial tissue that is involved
in the propagation of the dysrhythmia. Radiofre-
quency ablation generates an alternating electri-
cal current that passes through myocardial tissue,
creating heat energy that conducts to deeper tissue
layers. At temperatures of 50°C or higher, most tis-
sues undergo irreversible coagulation necrosis and
then evolve into nonconducting myocardial scar
tissue.14,15 Cryoablation destroys tissue by freezing.
The principal objective of atrial fibrillation abla-
tion is the electrical disconnection of the pulmo-
nary-vein triggers from the atrial substrate (often
called “pulmonary-vein isolation”).16,17 To achieve
this goal, ablation is performed around the pul-
monary-vein orifice (Fig. 1 and 2). Ablation of
sites beyond the pulmonary vein–left atrial junc-
tion in the atrial substrate itself, targeting so-
called complex fractionated electrograms, is not
necessary in paroxysmal atrial fibrillation but may
be very important in patients with persistent
atrial fibrillation.17
The Food and Drug Administration (FDA) are also performed in patients with persistent
has approved both radiofrequency ablation and or permanent atrial fibrillation, although such
cryoablation for clinical use in patients with par- use is not FDA-approved and is considered off-
oxysmal atrial fibrillation. Ablation procedures label.

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 The n e w e ng l a n d j o u r na l of m e dic i n e

to catheter ablation and 17% of those assigned

Before ablation After ablation to antiarrhythmic drug therapy were free of recur-
I rent atrial tachyarrhythmias. Patients in the abla-
V5
Abld
tion group also had significantly greater improve-
L1–2 ment in quality of life.
L2–3 Cryoablation has also been shown to be effec-
L3–4 tive, although the results of the principal random-
L4–5
L5–6
ized trial of this technique, Sustained Treatment
L6–7 of Paroxysmal Atrial Fibrillation (STOP AF;
L7–8 ClinicalTrials.gov number, NCT00523978), have
L8–9
not yet been published. In the STOP AF trial, 245
L9–10
L10–11 patients with paroxysmal atrial fibrillation in
CSd whom previous antiarrhythmic drug therapy had
CSp failed were randomly assigned to treatment with
STIM
a cryoablation balloon or antiarrhythmic drugs.
300 msec
One year after treatment, 69.9% of the patients
Figure 2. Electrographic Recordings before and after Ablation. treated with cryoablation had no detectable atrial
Electrographic recordings of electrocardiographic leads I and V5 and from fibrillation, as compared with 7.3% of those who
electrodes positioned within the atrium (L1–2 through L10–11), in the proxi- were treated with antiarrhythmic medications.25
mal and distal coronary sinus (CSp and CSd), and on the ablation catheter An important limitation of the evidence is that
itself (Abld) are shown. Stimuli to initiate atrial depolarizations are adminis-
tered through a stimulating electrode (STIM). Arrows point to pulmonary-
atrial fibrillation ablation has not yet been stud-
vein potentials recorded with the use of a circular mapping catheter. These ied for its potential impact on important clinical
potentials are present before ablation but disappear after ablation, indicating
COLOR FIGURE outcomes such as the rates of death, stroke, heart
that pulmonary vein–left atrial electricalDraft
disconnection
1 and pulmonary-vein
11/17/11 failure, or health care utilization.
isolation have been achieved. Author Saliba
Fig # 2
Title CL INIC A L USE
ME
CL INIC
DE A L E V IDENCE
Jarcho Management of atrial fibrillation hinges on de-
Artist TV
AUTHOR PLEASE NOTE:
creasing the risk of stroke, preventing the devel-
Several randomized trials have shown superior
Figure has been redrawn and type has been reset
Please check carefully
opment of heart failure, and relieving symptoms.
outcomes for radiofrequency
Issue date 12/15/11 ablation as compared For some patients, maintenance of sinus rhythm
with antiarrhythmic drug therapy.18-24 For example, is not essential, and indeed, a strategy of attempt-
in one trial, 198 patients with paroxysmal atrial ing to maintain sinus rhythm specifically with
fibrillation in whom antiarrhythmic drug therapy antiarrhythmic drugs has not been shown to re-
had previously failed were randomly assigned to duce mortality.26,27 However, some patients re-
either radiofrequency ablation or antiarrhythmic main very symptomatic while in atrial fibrilla-
drug therapy with other agents.21 Patients as- tion, despite rate control, and for such patients a
signed to catheter ablation received antiarrhyth- rhythm-control approach may be preferable.
mic drug therapy for the first 6 weeks after treat- Antiarrhythmic drugs are considered the first-
ment, and recurrences during this interval were line treatment for maintenance of sinus rhythm.
not included in the primary trial end point (a so- However, the efficacy of these agents is not fa-
called blanking period to allow healing of the vorable, with only 50% of patients so treated main-
atrial myocardium after the procedure). At 1 year, taining sinus rhythm after 1 year of follow-up.26 In
86% of the patients assigned to catheter ablation addition, the side effects of antiarrhythmic drugs
and 22% of those assigned to antiarrhythmic drug are not trivial. In a recent meta-analysis, these side
therapy had not had a recurrent atrial tachyar- effects included treatment-related death in 0.5% of
rhythmia (P<0.001). Hospitalizations for cardio- patients, torsades de pointes in 0.7%, neuropathy
vascular disease were also less frequent in the ab- in 5.0%, and thyroid dysfunction in 3.3%.28 Less
lation group. serious side effects such as gastrointestinal symp-
In another trial, 167 patients with drug-resis- toms occur more frequently and may have a sub-
tant paroxysmal atrial fibrillation were randomly stantial effect on quality of life.
assigned to ablation or another antiarrhythmic Catheter ablation is indicated to prevent the
drug.22 At 9 months, 63% of the patients assigned recurrence of symptomatic atrial fibrillation in

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 clinical ther apeutics

patients in whom medical therapy has been in-

effective. It is important to note that most ran- A Circular
mapping
domized studies included only patients with par- catheter
oxysmal atrial fibrillation and that the FDA has RSPV
approved catheters for use only in such patients. LSPV
However, ablation of persistent or permanent
atrial fibrillation in symptomatic patients in whom
medical therapy has failed is reasonable, since LIPV
such patients have been shown to have consider-
RIPV
able symptom relief with a successful ablation.17 Ablation
catheter
Ablation is most effective in patients with parox-
ysmal atrial fibrillation and less effective in pa-
tients with persistent atrial fibrillation, heart
failure, or valvular disease. The desire to discon-
tinue oral anticoagulation by itself is not a valid
indication to refer a patient for atrial fibrillation
ablation. The presence of a left atrial thrombus
is a contraindication to catheter ablation, and all
patients who present in atrial fibrillation should B
Ablation
have either clear documentation of therapeutic LSPV catheter
anticoagulation for at least 6 weeks before the RSPV
procedure or a transesophageal echocardiogram
showing that no thrombus is present. Circular
mapping
Ablation may be performed while the patient LIPV catheter
is under intravenous conscious sedation or gen-
eral anesthesia. Access to the pulmonary veins in RIPV
the left atrium is achieved by inserting sheaths
into the femoral veins and advancing catheters to
the inferior vena cava and right atrium, and then
crossing the interatrial septum by transseptal
puncture with a specially designed needle. Hep-
arin is administered for prevention of thrombosis
either just before or just after transseptal puncture.
Figure 3. Electroanatomical Mapping of the Left Atrium.
The procedure is performed with the use of
Panel A shows the anterior view of an electroanatomical map of the pulmo-
fluoroscopy and, in some cases, with guidance
nary veins and the anterior wall of the left atrium. The circular mapping
from electroanatomical mapping (a tool that uses catheter appears as a red ring, and the ablation catheter asCOLORa white
FIGURE
cylinder
a specialized recording catheter with location sen- with a green tip. Panel B shows the posterior view ofDraft
an 1electroanatomical
11/17/11
sors to create a three-dimensional anatomical map of the pulmonary veins and the posterior wall Saliba
of the
Author left atrium. The
reconstruction of the left atrium with superimposed
Fig #
circular mapping catheter appears as a red ring, and the3 ablation catheter
Title
as a white cylinder with a green tip. LIPV denotes left inferior pulmonary
electrical activation data) (Fig. 3). Intracardiac echo-
vein, LSPV left superior pulmonary vein, RIPV rightME inferior pulmonary vein,
cardiography is used in many laboratories to guide and RSPV right superior pulmonary vein. DE Jarcho
transseptal puncture under direct visualization Artist TV
AUTHOR PLEASE NOTE:
(Fig. 4) and also to guide pulmonary-vein isola- Figure has been redrawn and type has been reset
Please check carefully
tion.29 With intracardiac echocardiography, it is erated by the procedure into the esophagus Issue
with
date a 12/15/11
possible to visualize the antrum of each pulmo- consequent risk of esophageal injury.
nary vein and position the catheters for ablation Ablation around the antrum of each pulmo-
appropriately. It also aids in the early detection nary vein is performed to achieve complete elec-
of complications such as thrombus formation and trical disconnection between the pulmonary vein
pericardial effusion.30 During radiofrequency ab- and left atrium (pulmonary-vein isolation). With
lation, a thermistor probe is inserted through the radiofrequency ablation, this goal is achieved by
patient’s nose or mouth into the esophagus to the sequential application of radiofrequency en-
monitor esophageal temperatures; an increase in ergy at a series of individual closely spaced points
temperature implies transmission of the heat gen- around the circumference of the vein. With cryoab-

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 The n e w e ng l a n d j o u r na l
A lation of complex fractionated electrograms may
B statement on catheter and surgical ablation of
Interatrial septum
Left atrium
Circular mapping catheter
Figure 4. Intracardiac Echocardiographic Images.
Panel A shows transseptal puncture. The triangular
echodensity indicates tenting of the interatrial septum
with the transseptal needle (arrow). Panel B shows the
interatrial septum, left atrium, and circular mapping
catheter in a large common pulmonary vein.
lation, a balloon-tipped catheter is advanced to the
antrum of each pulmonary vein and the balloon is
inflated to form a seal. The balloon is then filled
with coolant, which creates a circumferential zone
of tissue necrosis around the vein orifice.
With successful pulmonary-vein isolation, ec-
topic electrical triggers arising in the pulmonary
veins encounter a region of scarring that obstructs
the propagation of electrical impulses to the
atrium. Isolation is confirmed by the absence of
electrograms at the pulmonary vein–left atrial
junction or by a reduction in the amplitude of such
electrograms, which is usually detected with the
use of a circular mapping catheter (Fig. 2). Dur-
ing the procedure, a nonpulmonary-vein trigger
(e.g., arising in the body of the left atrium) may be
recognized as a contributing cause of atrial fibril-
lation and is then targeted for ablation. In patients
with persistent atrial fibrillation, pulmonary-vein
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Copyright © 2011 Massachusetts Medical Society. All rights reserved.
of m e dic i n e
isolation may not be sufficient, and adjunctive ab-
be performed elsewhere in the atrium.
Patients are observed overnight and discharged
the following morning. After discharge, patients
are often treated with an antiarrhythmic drug for
2 or 3 months to minimize early recurrence of
atrial fibrillation. Oral anticoagulation should be
continued for at least 2 months after ablation.
Patients are provided with event monitors for
several months after ablation and are asked to
transmit rhythm data weekly and whenever symp-
toms are reported. The 2007 expert consensus
atrial fibrillation by the Heart Rhythm Society, the
European Heart Rhythm Association, and the Eu-
ropean Cardiac Arrhythmia Society (HRS/EHRA/
ECAS) recommends 24-hour Holter monitoring
every 3 to 6 months for at least 2 years.17 Recur-
rence of atrial fibrillation in the first 3 months
may be attributable to inflammation and irrita-
tion caused by the ablation; the risk of further
recurrence typically abates as the inflammation
resolves. However, data suggest that recurrences
later in this period are associated with long-term
recurrence.31,32
Patients should be evaluated within 3 to
4 months to assess the outcome of ablation.
During long-term follow-up, one of four possible
outcomes may be encountered. Some patients are
found to be apparently free of atrial fibrillation,
based on both symptoms and rhythm monitor-
ing, even after discontinuation of antiarrhythmic
drugs. A second group has recurrent atrial fibril-
lation that can be controlled with previously in-
effective drugs; in such patients, a second abla-
tion can be deferred. A third group of patients
has recurrent symptomatic atrial fibrillation de-
spite antiarrhythmic drug therapy; a second abla-
tion is indicated in such patients. Finally, a fourth
group of patients has recurrent, but asymptom-
atic, atrial fibrillation. Such patients can be treated
with rate control.
Recurrent atrial fibrillation is common after
catheter ablation. One article described outcomes
in 831 patients.33 At 1 year, 633 (76%) were free of
arrhythmia, 17 (2%) had recurrence managed with
antiarrhythmic drugs, 161 (19%) had recurrence
managed with a second ablation, and 20 (2%) had
recurrence managed with rate control.
Regardless of the apparent efficacy of ablation,
the guidelines recommend that anticoagulation
nejm.org december 15, 2011
 clinical ther apeutics
in the long term (after 2 months) should be based
on the risk of stroke as predicted by the CHADS2
score. The CHADS2 score is a risk-prediction score,
with values ranging from 0 to 6, that assigns one
point each for congestive heart failure, hyperten-
sion, age of 75 years or older, and diabetes, and
two points for stroke or transient ischemic attack.
Typically, therapeutic anticoagulation is recom-
mended for patients with a CHADS2 score of
2 or more. The rationale for this approach is that
asymptomatic recurrence of atrial fibrillation can-
not be ruled out as a possibility, even among pa-
tients who have undergone apparently very suc-
cessful ablation.
In the United States, the initial cost of atrial
fibrillation ablation is between $17,000 and
$25,000. There is an additional cost of about
$1,500 to $2,000 per year thereafter for monitor-
ing and follow-up visits.
A DV ER SE EFFEC T S
A recently published survey reported data on
16,309 patients undergoing atrial fibrillation ab-
lation worldwide, including data on adverse
events. Almost all the procedures in this survey
were performed with the use of radiofrequency
ablation; cryoablation was used in less than 2% of
cases. In this survey, the risk of a major complica-
tion was 4.5%.29 The risk of death was 0.15%.
Cardiac tamponade due to perforation is a
potentially life-threatening complication occur-
ring in approximately 1.3% of patients undergo-
ing atrial fibrillation ablation. Cardiac perforation
can be secondary to a misdirected transseptal
puncture, trauma due to catheter movement, or
excessive focal application of radiofrequency en-
ergy. Direct injury to the phrenic nerve can also
occur as a result of ablation near the right supe-
rior pulmonary vein and superior vena cava. Such
injury can cause diaphragmatic paralysis. Esoph-
ageal injury has been reported in approximately
10% of patients; atrioesophageal fistulas are rare
(occurring in 0.04% of patients) but can be dev-
astating and even lethal.
Cerebrovascular thromboembolism has been
reported to occur in up to 2% of patients. Throm-
boembolic complications can arise because of clot
or char formation on the sheaths and catheters or
at the site of ablation. The diagnosis is usually
made during the procedure, but thromboemboli
can occur several days later.
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Pulmonary-vein stenosis is a late complication
of ablation caused by injury to the pulmonary-
vein musculature. The reported incidence varies
from 0 to 10%. Symptoms of pulmonary-vein ste-
nosis include chest pain, shortness of breath,
cough, and recurrent lung infections. The diagno-
sis is made with the use of computed tomographic
imaging or magnetic resonance scanning or by
means of ventilation–perfusion lung scanning.
Iatrogenic atypical flutter, a type of regular
atrial arrhythmia encountered after ablation, can
result from ablation lines that do not completely
isolate the pulmonary veins. The occurrence of
this complication depends to a large extent on the
technique of ablation; the incidence ranges from
1.8 to 14.3%. Other, less frequent, complications
are listed in Table 1.17,29
A r e a s of Uncer ta in t y
The success of atrial fibrillation ablation is variable,
and there is evidence that some of this variation is
operator-dependent. High success rates and low
complication rates are achieved in high-volume, ex-
perienced centers. Furthermore, results from vari-
ous centers and studies differ greatly because of
variations in technique, reporting, and follow-up.
Greater standardization of practice is therefore nec-
essary to achieve consistency in clinical outcomes.
The restoration of sinus rhythm by catheter
ablation of atrial fibrillation improves quality of
life and may improve the left ventricular ejection
fraction in patients with heart failure. However,
the long-term effect of this procedure requires
further study; this is especially true in patients
with persistent, long-standing atrial fibrillation
and enlarged atria. In addition, the durability of
maintenance of sinus rhythm after ablation in
the long term is unknown. Preliminary data sug-
gest that the recurrence rate after the first year is
6 to 9% per year.33-36
Although some retrospective studies suggest
that oral anticoagulation may be discontinued
safely in selected patients after successful ablation,
there is no definitive evidence that maintenance
of sinus rhythm after ablation decreases the risk
of stroke. Given the risk of asymptomatic (silent)
recurrent atrial fibrillation, the true recurrence
rate is underestimated. As a result, discontinu-
ing oral anticoagulation in patients in whom the
CHADS2 score is greater than 1 is problematic
and requires vigilant and frequent follow-up.
2301
 The n e w e ng l a n d j o u r na l of m e dic i n e

Table 1. Adverse Effects of Ablation for Atrial Fibrillation.*

Adverse Effect Incidence Recommended Monitoring Management

%
Death 0.15
Cardiac tamponade 1.2–6.0 Blood-pressure monitoring, examination of Reversal of anticoagulation, immediate
­cardiac silhouette on chest radiographic pericardiocentesis, surgery if accu-
study, echocardiography mulation is ongoing
Stroke 0–2 Neurologic examination Depends on center; consider thrombol-
ysis or intervention
Pulmonary-vein stenosis 0.5–2.0 CT or MRI 3–4 mo after ablation If stenosis is severe, with symptoms,
then dilation and possible stenting
of the pulmonary vein or veins

Phrenic-nerve injury 0–11 Fluoroscopy Most patients recover without treatment

Regular atrial arrhythmia† 5–25 Transtelephonic monitoring, Holter monitoring, Antiarrhythmic drugs, perform ablation
use of implantable loop recorder again

Vascular complications 0.5–5.0 Vascular ultrasonography Percutaneous or open vascular surgery

(arteriovenous fistula,
­pseudoaneurysm)

Esophageal injury with 10 Esophageal temperature probe Most patients heal without treatment
­ulceration

Atrioesophageal fistula 0.04 Maintain high index of suspicion for this com- Surgery
plication (symptoms such as fever, chills,
recurrent neurologic events, or sepsis occur
2–4 wk after ablation); CT or MRI

* CT denotes computed tomography, and MRI magnetic resonance imaging.

† “Regular atrial arrhythmia” is a term used to describe both atrial tachycardia and an atypical form of atrial flutter after ablation that can
­occur with incomplete pulmonary-vein isolation.

Guidel ine s lar function, and no severe pulmonary disease.”37

In 2007, the expert consensus statement on cath-
eter and surgical ablation of atrial fibrillation by
the HRS/EHRA/ECAS concluded that the primary
indication for catheter ablation is the presence of
symptomatic atrial fibrillation that is refractory
or intolerant to at least one class 1 or class 3 anti­
arrhythmic drug. It also concluded that catheter
ablation is appropriate in selected symptomatic
patients with heart failure, a reduced ejection
fraction, or both.17 The 2011 update to the guide-
lines for the treatment of patients with atrial fi-
brillation by the American College of Cardiology,
the American Heart Association, and the HRS
states that “catheter ablation performed in expe-
rienced centers is useful in maintaining sinus
rhythm in selected significantly symptomatic pa-
tients who have failed treatment with an antiar-
rhythmic drug and have normal or mildly dilated The patient in the vignette has highly symptom-
left atria, normal or mildly reduced left ventricu- atic atrial fibrillation. His dysrhythmia has pro-
The 2011 European Society of Cardiology guide-
lines also endorse catheter ablation for paroxys-
mal and persistent atrial fibrillation in symptom-
atic patients in whom antiarrhythmic therapy
has failed.38 These guidelines further state that
ablation may be considered in patients with symp-
tomatic paroxysmal atrial fibrillation and no clin-
ically significant underlying disease before antiar-
rhythmic drug therapy. The 2010 atrial fibrillation
guidelines of the Canadian Cardiovascular Society
recommend “catheter ablation of atrial fibrillation
in patients who remain symptomatic following ad-
equate trials of anti-arrhythmic drug therapy and
in whom a rhythm control strategy remains de-
sired.”39
R ec om mendat ions

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Copyright © 2011 Massachusetts Medical Society. All rights reserved.
 clinical ther apeutics

gressed from paroxysmal to persistent atrial fi-
brillation despite antiarrhythmic drug therapy.
He would be a suitable candidate for pulmonary-
vein isolation with either radiofrequency ablation
or cryoablation, with a projected success rate of
80 to 85%. If he were allowed to lapse into per-
manent atrial fibrillation, the success rate would
be lower. The physician is obligated to provide
the patient with unbiased information and to ex-
plain the possible outcomes and complications
of ablation. It should be stressed that ablation is
performed for symptom relief and to improve the
quality of life and that it has not been proved to
decrease the risk of stroke or to improve longev-
ity. The patient should be informed that compre-
hensive arrhythmia monitoring and follow-up
will be needed after the ablation and that recur-
rence of atrial fibrillation is common and may
require another trial of antiarrhythmic drugs or
a second ablation. It is important to emphasize
that even if the ablation is successful, the deci-
sion to discontinue oral anticoagulation must be
weighed very carefully and discontinuation may
be inadvisable. Extended monitoring may be re-
quired to make this decision.
No potential conflict of interest relevant to this article was
reported.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.

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2. Miyasaka Y, Barnes ME, Gersh BJ, et al.
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3. Fuster V, Rydén LE, Cannom DS, et al.
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Task Force on Practice Guidelines devel-
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