In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

Background: Catheter ablation as first-line therapy for ventricular tachycardia (VT) at the time of implantable cardioverter defibrillator (ICD) implantation has not been adopted into clinical guidelines. Also, there is an unmet clinical need to prospectively examine the role of VT ablation in patients with nonischemic cardiomyopathy, an increasingly prevalent population that is referred for advanced therapies globally. Methods: We conducted an international, multicenter, randomized controlled trial enrolling 180 patients with cardiomyopathy and monomorphic VT with an indication for ICD implantation to assess the role of early, first-line ablation therapy. A total of 121 patients were randomly assigned (1:1) to ablation plus an ICD versus conventional medical therapy plus an ICD. Patients who refused ICD (n=47) were followed in a prospective registry after stand-alone ablation treatment. The primary outcome was a composite end point of VT recurrence, cardiovascular hospitalization, or death. Results: Randomly assigned patients had a mean age of 55 years (interquartile range, 46–64) and left ventricular ejection fraction of 40% (interquartile range, 30%–49%); 81% were male. The underlying heart disease was ischemic cardiomyopathy in 35%, nonischemic cardiomyopathy in 30%, and arrhythmogenic cardiomyopathy in 35%. Ablation was performed a median of 2 days before ICD implantation (interquartile range, 5 days before to 14 days after). At 31 months, the primary outcome occurred in 49.3% of the ablation group and 65.5% in the control group (hazard ratio, 0.58 [95% CI, 0.35–0.96]; P =0.04). The observed difference was driven by a reduction in VT recurrence in the ablation arm (hazard ratio, 0.51 [95%CI, 0.29–0.90]; P =0.02). A statistically significant reduction in both ICD shocks (10.0% versus 24.6%; P =0.03) and antitachycardia pacing (16.2% versus 32.8%; P =0.04) was observed in patients who underwent ablation compared with control. No differences in cardiovascular hospitalization (32.0% versus. 33.7%; hazard ratio, 0.82 [95% CI, 0.43–1.56]; P =0.55) or mortality (8.9% versus 8.8%; hazard ratio, 1.40 [95% CI, 0.38–5.22]; P =0.62]) were observed. Ablation-related complications occurred in 8.3% of patients. Conclusions: Among patients with cardiomyopathy of varied causes, early catheter ablation performed at the time of ICD implantation significantly reduced the composite primary outcome of VT recurrence, cardiovascular hospitalization, or death. These findings were driven by a reduction in ICD therapies. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02848781.

Background: Circumferential pulmonary vein isolation (CPVI) alone or combined with adjuvant substrate modifications is unsatisfactory for atrial fibrillation (AF) control in nonparoxysmal AF patients. Ablation targeting the fibrotic areas after CPVI (STABLE-SR [Electrophysiological Substrate Ablation in the Left Atrium During Sinus Rhythm]) is a newly evolved substrate modification strategy. Methods and Results: In this multicenter, randomized clinical trial, 229 symptomatic nonparoxysmal AF patients were 1:1 randomized to STABLE-SR group (n=114) or conventional STEPWISE group (n=115). In the STABLE-SR group, after CPVI, cavotricuspid isthmus ablation and cardioversion to sinus rhythm, left atrial high-density mapping was performed. Areas with low-voltage and complex electrogram were further homogenized and eliminated, respectively. Dechanneling would be done if necessary. In the STEPWISE group, additional linear lesions and defragmentation were performed.The primary end point was freedom from documented atrial tachyarrhythmias for ≥30 s after a single ablation procedure without antiarrhythmic medications at 18 months. At 18 months, 74.0% of the patients in the STABLE-SR group and 71.5% in the STEPWISE group (hazard ratio, 0.78; 95% confidence interval, 0.47–1.29; P =0.325) achieved success according to intention-to-treat analysis. However, less procedure time (186.8±52.7 versus 210.5±48.0 minutes, P <0.001), reduced post-CPVI fluoroscopic time (11.0±7.8 versus 13.7±8.9 minutes, P =0.006), and shorter energy delivery time (60.1±25.1 versus 75.0±24.3 minutes, P <0.001) were observed in the STABLE-SR group compared with the STEPWISE group. Conclusions: STABLE-SR is a simplified, personalized, and effective ablation strategy in nonparoxysmal AF patients. More importantly, over 50% nonparoxysmal AF patients do not need further ablation beyond CPVI and therefore can avoid excessive ablation. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT01761188.