Adopting and Implementing the AF Ablation Consensus Statement

The AFib Summit, held during the Heart Rhythm 2007 Annual Scientific Sessions, May 9-10, in Denver, Colorado, featured world-renowned experts who presented the latest in the diagnosis, management, drug therapy, outcomes, and ablation techniques for atrial fibrillation (AF). Sessions during the AFib Summit covered the following topics: AF mechanisms; clinical outcomes of AF ablation; new generation imaging for ablative interventions; facilitating good outcomes and avoiding bad ones; anti-thrombotic, anti-arrhythmic, and anti-inflammatory drug therapy for AF; how to perform ablative intervention; special considerations for non-pharmacologic therapies; and the means by which to pull it all together. A highlight of the AFib Summit was the release of a revised consensus statement on atrial fibrillation. In this article, the central components of the HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation are described as well as how the incorporation of the statement s guidelines will impact treatment of atrial fibrillation in the future. The AFib Summit featured a special presentation that summarized the newly released consensus statement on ablation of AF, which was followed by an interactive panel discussion with the experts in AF. In this article, we will summarize both the consensus statement and the panel discussion. Summary of the Presentation on The Heart Rhythm Society/Expert Consensus Statement on AFib Ablation: What Do We Know, What Should We Do? Hugh Calkins, MD, co-chair of the AFib Summit, described the HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation as a state-of-the-art review of the field of catheter and surgical ablation of AF. The consensus statement reports the findings of a Heart Rhythm Society (HRS) task force charged with defining the indications, techniques, and outcomes of these procedures. The statement was written in joint partnership with the European Heart Rhythm Association (EHRA) and European Cardiac Arrhythmia Society (ECAS) and endorsed by the American Heart Association, American College of Cardiology, and Society of Thoracic Surgeons. The statement was released electronically just prior to Heart Rhythm 2007, and was published in the HRS and EHRA journals in June 2007.¹ The consensus statement summarizes the opinions of 27 task force members, who have been recognized as the world s most prominent leaders in the field of electrophysiology (EP). Task force members received a survey and responded based on their own experiences in treating patients. Aspects of AF ablation that represented a true consensus were identified and described in the document, which also includes a review of the literature. Dr. Calkins stated that the statement has been well received by the community of electrophysiologists who care for patients with atrial fibrillation and/or perform catheter ablation procedures. From a clinical perspective this document has been well received for several reasons. First, the document has provided clear indications and contraindications for performing AF ablation procedures. This has been very useful in discussing the complexities of the procedure with patients. Second, the consensus document has clarified that electrical isolation of the pulmonary veins is the primary objective of an AF ablation procedure, particularly when performed for patients with paroxysmal atrial fibrillation. Third, the document has provided fairly specific advice concerning anti-coagulation strategies prior to, during, and following AF ablation procedures. And finally, the consensus document has clarified the length of the blanking period following AF ablation, which helps determine when repeat ablation procedures should be considered. An additional component of the statement, which has been well received by the EP community, is the detailed description of the potential complications associated with AF ablation. This has been particularly useful to clinicians who are faced with deciding when some of the most serious complications, such as an atrial - esophageal fistula, should be screened for. The Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation has also had a positive impact on the community of academic electrophysiologists who are involved in reporting the outcomes of clinical trials of AF ablation. Soon after the consensus document was published, reviewers for many of the major medical journals have insisted that the consensus statement s recommendations for reporting outcomes be adhered to. This includes using a standardized definition of success: "Freedom from symptomatic or asymptomatic atrial fibrillation/flutter/ tachycardia or more than 10 minutes duration off antiarrhythmic drug therapy"; as well as insisting that clinical trials report single procedure outcomes. Another important recommendation of the consensus document was that compliance with monitoring protocols for asymptomatic atrial fibrillation be provided and the results of this monitoring reported. It is reassuring to see that reviewers of articles for medical journals are voluntarily acting as "policemen" to raise the standards for reporting the outcomes of clinical trials of AF ablation to those recommended by the Consensus Document. It is clear that this consensus statement has had a significant impact in the EP medical commuity. Patient care is improving and the quality of clinical research in this field is also witnessing improvement in its standards and guidelines. Summary of Expert Panel Discussion: Adopting and Implementing the AF Ablation Consensus Statement Doug L. Packer, MD, co-chair of the AFib Summit, convened members of the expert panel discussion, stating to the audience that panelists would provide their opinion on the document: where it fits in the treatment of AF and guidelines in general, where it fits overall in the management of AF, and what impact it may have on the practice of medicine. Peter R. Kowey, MD, session chair, argued that the consensus statement should not be used as a guideline, as it merely summarizes opinions and does not include solid data to support any of the approaches. Albert L. Waldo, MD, echoed that sentiment, insisting the document is state-of-the-art and should not be considered a guideline; despite the opinion of these two experts, the statement does outline the need for more clinical trials in order to obtain data that is lacking. Josep Brugada, MD, PhD, elaborated that the growing technique for AF ablation has been expanding so fast there has been no time to provide highly accurate data. Still, he believes a consensus agreement based on the input of experienced physicians is important, as it shows the status of what physicians performing AF ablation know and summarizes the latest expert opinions with regard to this technique. Kenneth Ellenbogen, MD, explained that the clinical trials section of the document is important, as it has established a framework to guide investigators so trials will be reported in a uniform way. In addition, he said the statement is valuable to physicians because it outlines what information to tell patients. For example, the vocabulary section provides definitions on the various types of AF, complications, appropriate follow-up, and success and failure. David J. Callans, MD, stated that the document provides a framework on the minimal standards for how efficacy and safety results should be reported. He urged EPs to maintain these minimal standards so credibility is not lost. Paul A. Friedman, MD, said the document highlights the importance of educating both patients and referring physicians, and believes the consensus will have a true impact on patient outcomes. The document will set expectations, for instance, by letting patients know potential complications and how they are presented. The document s strength is providing a dialog for future research and a state-of-the art summary that will hopefully improve patient care, stated Dr. Friedman.