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Amazing Evolution of Catheter Ablation Guidelines

by Steve S. Ryan, PhD

Dr. Jeremy Ruskin of Massachusetts General Hospital in Boston discussed how and why the recent guidelines now list catheter ablation as first line choice for treating paroxysmal A-Fib.

(“First line” means as a patient you can now choose to have a catheter ablation without having tried and failed antiarrhythmic drugs as in the recent past. But according to the guidelines, doctors must talk to you about both options. Most doctors will encourage you to try antiarrhythmic meds first. Even though catheter ablation is a low risk procedure, there is still some risk.

Most antiarrhythmic meds aren’t all that effective, tend to have bad side effects, and lose their effectiveness over time. Young people in particular can’t expect to live the rest of their lives on antiarrhythmic meds. And unless the antiarrhythmic med works 100% of the time, you risk remodeling your heart, developing fibrosis which is irreversible, etcBut it’s up to you to get all the facts about antiarrhythmic drugs and make your own decision (along with your doctor of course). In this decision your doctor will probably lean toward having you spend a year trying various antiarrhythmic meds. But according to the guidelines you don’t have to do that.)

Medical innovations normally take a good deal of time to be accepted and go into widespread use. But that’s not the case for catheter ablation of A-Fib. It’s amazing how fast catheter ablation has been adopted as therapy for making people A-Fib free. Back in 2002-2003 when the author started the web site, he tried to list where one could go to get a catheter ablation (Pulmonary Vein Isolation—PVI) procedure. He could only find seven facilities doing PVIs. Now there are well over 1,000 facilities in the U.S. alone, and many more throughout the world. Catheter ablation (PVI) has been one of the fastest adopted medical innovations in the history of medicine.

Dr. Ruskin in a very informative presentation discussed how catheter ablation (PVI) evolved rapidly from being almost an afterthought in clinical guidelines to becoming first line therapy.

Back in 2001, non-pharmacologic therapy was listed in the guidelines (ACCA/ACA/EHRA) as a last-line option. Catheter ablation wasn’t even mentioned specifically but was just lumped together with non-pharmacologic therapy.

But as doctors developed skills in catheter ablation (PVI) and it became widely recognized and used, in 2006 catheter ablation was recognized in guidelines as a second-line option in patients with symptomatic recurrent paroxysmal A-Fib (PAF) who had little or no atrial enlargement.

Four years later in 2010 ESC guidelines again suggested that catheter ablation should be considered in symptomatic patients with PAF who had previously failed a trial of anti-arrhythmic drug therapy (second line). However, these guidelines did also state that catheter ablation could be considered prior to anti-arrhythmic drug therapy in selected patients (which is sort of a back-door way of making catheter ablation a first line therapy for selected patients. The author remembers when these new guidelines appeared, and the euphoria some doctors and patients felt that they now could legitimately go right to catheter ablation without having to first try an antiarrhythmic med.)

In 2011 the major change was that catheter ablation as a second line therapy was now upgraded from a class IIa indication, which should be “considered” to a class I indication which is “recommended.”

And in 2012 ESC published updated guidelines where, for the first time, the statement was made that catheter ablation should be considered as a first line therapy in selective patients with symptomatic paroxysmal A-Fib; and as an alternative to antiarrhythmic therapy based on patient choice and balance of benefit and risk.

(According to current guidelines, “stand-alone surgical ablation of AF is not recommended as a first line therapy.” It’s listed as Class IIb. The Society of Thoracic Surgeons participated in and endorsed these guidelines.)

It should be noted that current guidelines are truly a consensus statement agreed to and endorsed by every major medical group representing doctors who deal with A-Fib. In the second footnote is a list of all the organizations participating in the consensus statement of guidelines.

Editor’s Comments
Catheter ablation (Pulmonary Vein Isolation—PVI) has come a long way in a very short time. Everyone with A-Fib should know or be informed that, according to current guidelines approved by every medical group dealing with A-Fib, you no longer have to spend months or a year trying antiarrhythmic meds that often don’t work and leave you feeling miserable. Doctors, however, must and will discuss with you the benefits and risks of catheter ablation versus antiarrhythmic meds. But you have a choice. Rather than having to live in A-Fib while trying different meds, you can go for a cure. It’s your choice.


Feld, G. K., “Hot Topics: A Review of the 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation.” Atrial Fibrillation A CardioSource Clinical Community, Friday, January 11, 2013. Last accessed Jan 24, 2013 URL:

HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-Up: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and Approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society.


Last updated: Tuesday, November 5, 2013

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