AF ablation — viva

Stem

Practice viva. The examiner describes a 60-year-old woman with symptomatic paroxysmal AF who asks about catheter ablation, and works through indications, the procedure, anticoagulation, complications and what happens afterwards.^[1]

Branch A — Should she have an ablation?

Examiner: She has not tried an antiarrhythmic drug. Can ablation be first-line?^[1][2]

Strong answer:

• ESC 2024: catheter ablation is recommended as a first-line option within a shared decision-making rhythm control strategy in paroxysmal AF, to reduce symptoms, recurrence and progression of AF (Class I, Level A).^[1]
• ACC/AHA 2023: in selected patients (generally younger with few comorbidities) with symptomatic paroxysmal AF in whom rhythm control is desired, ablation is useful as first-line therapy to improve symptoms and reduce progression to persistent AF (COR 1, LOE A); in patients other than younger patients with few comorbidities, with symptomatic paroxysmal or persistent AF managed with a rhythm-control strategy, first-line ablation can be useful to improve symptoms (COR 2a, LOE B-R).^[2]
• ESC 2024 recommends shared decision-making that takes account of procedural risks, likely benefits and risk factors for AF recurrence (Class I, Level C).^[1]

Follow-up: What is the evidence?^[2]

• ACC/AHA 2023 reports randomised trials of first-line ablation vs AADs in paroxysmal AF: recurrent atrial arrhythmias occurred in 43% with ablation vs 68% with AADs at 1-year follow-up in EARLY-AF, and in 25% vs 55% in STOP AF First, with procedural complications in 2% to 5% across MANTRA-AF, EARLY-AF and STOP AF First.^[2]
• It also notes that the average age in all 3 trials was 60 years or less.^[2]

Follow-up: And if her AF were persistent?^[1]

• ESC 2024: first-line ablation within a shared decision-making rhythm control strategy may be considered in selected patients with persistent AF (Class IIb, Level C); it says it is not clear whether first-line ablation is superior to drug therapy in persistent AF.^[1]

Branch B — The procedure

Examiner: What will the operator do, and how do they know it worked?^[2][3]

Strong answer:

• ACC/AHA 2023 recommends PVI as the primary lesion set for all patients undergoing AF ablation unless a different specific trigger is identified (COR 1, LOE A).^[2]
• The consensus defines the endpoint as electrical disconnection between the PVs and the LA, verified by entrance block and/or exit block; with contemporary technology, entrance block alone is an adequate endpoint.^[3]
• ACC/AHA 2023 rates the value of endpoints beyond PVI and of additional anatomical targets as uncertain (COR 2b, LOE B-R).^[2]

Follow-up: Radiofrequency, cryoballoon or pulsed field?^[3]

• The consensus says complication rates between RF and cryoablation do not seem to differ significantly, although the type differs: persistent phrenic nerve palsy almost exclusively after cryoablation, and oesophageal perforation, in the vast majority, after RF.^[3]
• In ADVENT, as the consensus reports it, 607 patients with drug-refractory paroxysmal AF were randomised to pulsed field or thermal ablation, and at 12 months pulsed field ablation was non-inferior for efficacy and safety.^[3]
• The newer 2026 scientific statement on pulsed field ablation from EHRA, HRS, APHRS, LAHRS and the Canadian Heart Rhythm Society says randomised controlled trials and large registries have confirmed its efficacy to be at least equivalent to thermal ablation, with generally shorter procedure times and lower complication rates, particularly oesophageal and phrenic nerve injury.^[14]

Branch C — Anticoagulation

Examiner: She takes apixaban. Walk me through anticoagulation.^[1][2]

Strong answer:

• Before: ESC 2024 recommends starting OAC at least 3 weeks before ablation in patients at elevated thromboembolic risk (Class I, Level C).^[1]
• During: uninterrupted OAC is recommended (ESC 2024, Class I, Level A); ACC/AHA 2023 says ablation should be performed with continuous or minimally interrupted DOAC (COR 1, LOE A).^[1][2]
• In the lab: the consensus reports a meta-analysis of 19 studies (7150 patients) in which an ACT above 300 s, compared with below 300 s, was associated with fewer thromboembolic complications without more bleeding. Separately, it states that evidence supports an initial heparin bolus before transseptal puncture.^[3]
• After: OAC is recommended for at least 2 months in all patients (ESC 2024, Class I, Level C), and ACC/AHA 2023 says it should be continued for at least 3 months, with a longer duration determined by underlying risk (COR 1, LOE B-NR).^[1][2]

Follow-up: A year later she is in sinus rhythm and wants to stop. What do you say?^[1]

• ESC 2024 recommends continuing OAC according to the CHA2DS2-VA score and not the perceived success of the ablation (Class I, Level C); ACC/AHA 2023 says longer-term OAC should be dictated by stroke risk, eg, CHA2DS2-VASc 2 or more (COR 1, LOE B-NR).^[1][2]
• The consensus says that in higher-risk patients (CHA2DS2-VASc 2 or more in men, 3 or more in women) anticoagulation should not be discontinued; in its intermediate-risk group, stopping may be considered 12 months after ablation in the absence of clinical symptoms or ECG-documented AF recurrence.^[3]
• OCEAN, an international, open-label, randomised trial with blinded outcome assessment in 1284 patients at least 1 year after successful ablation with a CHA2DS2-VASc score of 1 or more (2 or more for women or when vascular disease was the risk factor), found rivaroxaban 15 mg did not significantly lower a composite of stroke, systemic embolism or new covert embolic stroke compared with aspirin over 3 years of follow-up.^[8]

Branch D — Complications

Examiner: Her BP falls during the procedure. What are you thinking?^[3]

Strong answer:

• The consensus says hypotension during AF ablation should be assumed to indicate tamponade until proven otherwise; the diagnosis is confirmed by immediate echocardiography, and most tamponades can be managed successfully by immediate percutaneous drainage.^[3]
• UFH can be reversed with protamine, and if bleeding stops, reversal of OAC is not suggested (consensus).^[3]

Follow-up: Three weeks later she has fever and chest pain on swallowing.^[3]

• Suspect an atrio-oesophageal fistula: ACC/AHA 2023 Table 26 lists it at 1–4 weeks with chest pain, pain with swallowing, fever and stroke symptoms.^[2]
• The consensus prefers chest CT with intravenous contrast, contraindicates a barium swallow, advises against endoscopy with air insufflation, and calls treatment a medical emergency needing urgent surgical repair.^[3]

Branch E — After the ablation

Examiner: Two weeks after the procedure she has an episode of AF. Has the ablation failed?^[3]

Strong answer:

• Not necessarily: recurrence during the blanking period is not counted as treatment failure, and the consensus recommends an 8-week blanking period.^[3]
• If she had pulsed field ablation, the 2026 PFA scientific statement says a blanking period of just 1 month may be reasonable for clinical decision-making; it describes the 8-week period as applying to thermal ablation.^[14]
• ACC/AHA 2023 finds short-term AAD therapy after ablation can be useful in some patients to reduce early recurrences and hospitalisation (COR 2a, LOE A); ESC 2024 says a short-term AAD treatment (2–3 months) after ablation reduces early recurrences but does not affect late recurrences or 1-year clinical outcomes.^[2][1]
• For later symptomatic recurrence, ACC/AHA 2023 finds repeat ablation or AAD therapy useful (COR 1, LOE B-NR).^[2]