2012 CCS Atrial Fibrillation Guidelines Update
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Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
2016-03-22
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2012 CCS Atrial Fibrillation Guidelines Update
Canadian Cardiovascular Society Guidelines
2012 UPDATE
Atrial Fibrillation Guidelines:
Recommendations for Stroke Prevention and
Rate / Rhythm Control
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
CCS Atrial Fibrillation Guidelines
2012 Update
Primary Panel
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Allan Skanes (co chair)
Jeff Healey (co chair)
John Cairns
Stuart Connolly
Jafna Cox
Paul Dorian
Anne Gillis
Laurent Macle
Sean McMurtry
Gordon Gubitz
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Brent Mitchell
Stanley Nattel
Pierre Pagé
Ratika Parkash
P. Timothy Pollak
Michael Stephenson
Ian Stiell
Mario Talajic
Teresa Tsang
Atul Verma
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2012 CCS Atrial Fibrillation Guidelines Update
CCS AF Guidelines 2010
Primary Panel
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Anne Gillis (co chair)
Allan Skanes (co chair)
John Cairns
Stuart Connolly
Jafna Cox
Paul Dorian
Jeff Healey
Laurent Macle
Sean McMurtry
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Brent Mitchell
Stanley Nattel
Pierre Pagé
Ratika Parkash
P. Timothy Pollak
Michael Stephenson
Ian Stiell
Mario Talajic
Teresa Tsang
Atul Verma
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
CCS AF Guidelines 2010 ∕ 2012 Update
Secondary Panel
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Malcolm Arnold
David Bewick
Vidal Essebag
Milan Gupta
Brett Heilbron
Charles Kerr
Bob Kiaii
Jan Surkes
George Wyse
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2012 CCS Atrial Fibrillation Guidelines Update
Canadian Cardiovascular Society Atrial
Fibrillation Guidelines 2010:
Implementing GRADE and Achieving
Consensus
Anne M Gillis MD
Allan C Skanes MD
With special acknowledgement of
Jan Brozek MD, PhD
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2012 CCS Atrial Fibrillation Guidelines Update
A New Approach to Guideline
Development & Evaluation
GRADE
Grading of Recommendations, Assessment,
Development and Evaluation
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2012 CCS Atrial Fibrillation Guidelines Update
GRADE Approach
Clear separation of 2 issues:
1. Four Categories of Quality of Evidence:

High, Moderate, Low or Very Low
2. Strength of Recommendations: 2 Grades


Strong or Conditional (weak)
Quality of evidence only one factor
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
GRADE: Rating Quality of Evidence
Quality
Comments
Future research unlikely to change confidence in estimate of effect; e.g.
High
multiple well designed, well conducted clinical trails.
Further research likely to have an important impact on confidence in
Moderate
estimate of effect and may change the estimate e.g. limited clinical trials,
inconsistency of results or study limitations.
Further research very likely to have a significant impact in the estimate
Low
of effect and is likely to change the estimate e.g. small number of clinical
studies or cohort observations.
The estimate of effect is very uncertain; e.g. case studies; consensus
Very Low
opinion.
Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
Factors Determining the Strength of the Recommendation
Factor
Quality of Evidence
Difference between
desirable and
undesirable effects
Values and
Preferences
Cost
Comment
The higher the quality of evidence the greater the probability
that a strong recommendation is indicated. e.g. strong
recommendation that patients with AF at moderate to high risk
of stroke be treated with oral anticoagulants.
The greater the difference between desirable and undesirable
effects the greater the probability that a strong recommendation
is indicated e.g. strong recommendation that patients with AF ≥
48 hr duration receive oral anticoagulation therapy for at least 3
weeks prior to planned cardioversion and 4 weeks following.
The greater the variation or uncertainty in values and
preferences, the higher the probability that a conditional
recommendation is indicated e.g. ASA may be a reasonable
alternative to oral anticoagulant therapy in patients at low risk of
stroke.
The higher the cost the lower the likelihood that a strong
recommendation is indicated e.g. conditional recommendation
for catheter ablation as first line therapy for AF.
Modified with permission from: Guyatt GH, et al. BMJ 2008;336:926
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
2016-03-22
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2012 CCS Atrial Fibrillation Guidelines Update
Canadian Cardiovascular Society Atrial
Fibrillation Guidelines 2010: Etiology and
Investigation
Jeff S Healey MD
Ratika Parkash MD
P Timothy Pollak MD
Teresa SM Tsang MD
Paul Dorian MD
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2012 CCS Atrial Fibrillation Guidelines Update
Establish Pattern of Atrial Fibrillation
Newly Diagnosed AF
Paroxysmal
Persistent
Permanent
Modified with permission from Fuster et al Circulation 2006;114:e257-354
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
History
Establish Severity (including impact on QOL)
Identify Etiology
Identify reversible causes (hyperthyroidism, ventricular pacing, SVT,
exercise)
Identify factors whose treatment could reduce recurrent AF or
improve overall prognosis (i.e. hypertension, sleep apnea, left
ventricular dysfunction)
Identify potential triggers (i.e. alcohol, intensive aerobic training)
Identify potentially heritable causes of AF (particularly in lone AF)
Determine thromboembolic risk (e.g. CHADS2 Score)
Determine bleeding risk to guide appropriate antithrombotic therapy
Review prior pharmacologic therapy for AF, for efficacy and adverse
effects
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2012 CCS Atrial Fibrillation Guidelines Update
Physical Examination
Measure blood pressure and heart rate
Determine patient height and weight
Comprehensive precordial cardiac examination
Assessment of jugular venous pressure
Carotid and peripheral pulses to detect evidence of
structural heart disease
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2012 CCS Atrial Fibrillation Guidelines Update
12-Lead Electrocardiogram
Document presence of AF
Assess for structural heart disease (myocardial infarction,
ventricular hypertrophy, atrial enlargement, congenital heart
disease) or electrical heart disease (ventricular pre-excitation,
Brugada syndrome)
Identify risk factors for complications of therapy for AF
(conduction disturbance, sinus node dysfunction or
repolarization).
Document baseline PR, QT and QRS intervals.
Arrhythmia Monitoring Over Time (Holter or Event Recorder)
To document AF, assess efficacy of rate or rhythm control
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2012 CCS Atrial Fibrillation Guidelines Update
Echocardiogram
Assess ventricular size / LV wall thickness / function
Evaluate left atrial size (if possible, left atrial volume)
Exclude significant valvular or congenital heart
disease (particularly atrial septal defects)
Estimate ventricular filling pressures and pulmonary
arterial pressure
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2012 CCS Atrial Fibrillation Guidelines Update
Recommendations
Etiology and Investigations
All patients with AF should have a complete
history and physical examination,
electrocardiogram, echocardiogram, basic
laboratory investigations. Details are
highlighted in Table 1.
Strong
Recommendation
Low Quality
Evidence
Other ancillary tests should be considered
under specific circumstances. Details
included in Table 2.
Strong
Recommendation
Low Quality
Evidence
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
Practical Tips
• Aggressive treatment of hypertension may prevent
or reduce recurrences
• Choice of antihypertensive therapy should favor rate
controlling drugs e.g. β-blockers and Ca2+ channel
blockers vs inhibitors of renin angiotensin system.
• Identify and treat obstructive sleep apnea
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
Establish AF Severity
Use to Guide Therapeutic Approach
CCS
SAF Score
Impact on QOL
0
Asymptomatic
1
Minimal effect on QOL
2
Minor effect of QOL
3
Moderate effect on QOL
4
Severe effect on QOL
Dorian et al Can J Cardiol 2006;22:383-386
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
Recommendations
Quality of Life
We recommend that the assessment of
patient well ‐ being, symptoms, and quality
of life (QOL) be part of the evaluation of
every patient with AF.
Strong
Recommendation
Low Quality of
Evidence
We suggest that QOL of the AF patient can
be assessed in routine care using the
CCS‐SAF scale.
Conditional
Recommendation
Low Quality of
Evidence
Values and Preferences: These recommendations
recognize that improvement in QOL is a high priority for
therapeutic decision making.
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2012 CCS Atrial Fibrillation Guidelines Update
CCS SAF
Score
Impact
EHRA Class
Impact
CCS SAF 0
Asymptomatic
EHRA I
No symptoms
CCS SAF 1
Minimal effect
on QOL
EHRA II
CCS SAF 2
Modest effect
on QOL
EHRA III
CCS SAF 3
Moderate
effect on QOL
EHRA IV
CCS SAF 4
Severe effect
on QOL
Mild
symptoms
Severe
symptoms;
daily activity
affected
Disabling
symptoms;
Normal daily
activity
discontinued
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2012 CCS Atrial Fibrillation Guidelines Update
Canadian Cardiovascular Society Atrial
Fibrillation Guidelines 2012: AF/AFL
Rhythm Management
Anne M Gillis MD
Atul Verma MD
Mario Talajic MD
Stanley Nattel MD
Paul Dorian MD
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2012 CCS Atrial Fibrillation Guidelines Update
Overview of AF Management
Detection and
Treatment of
Precipitating Causes
AF Detected
Management of
Arrhythmia
Assessment of
Thromboembolic
Risk (CHADS2)
ASA
OAC
Rate
Control
Rhythm
Control
No antithrombotic therapy may be appropriate in
selected young patients with no stroke risk factors
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2012 CCS Atrial Fibrillation Guidelines Update
Goals of AF Arrhythmia
Management
• Identify and treat underlying structural heart disease
and other predisposing conditions
• Relieve symptoms
• Improve functional capacity/quality of life
• Reduce morbidity/mortality associated with AF/AFL
– Prevent tachycardia-induced cardiomyopathy
– Reduce/prevent emergency room visits or hospitalizations
secondary to AF/AFL
– Prevent stroke or systemic thromboembolism
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2012 CCS Atrial Fibrillation Guidelines Update
Recommendations – Rx Goals
We recommend that the goals of ventricular rate
control should be to improve symptoms and
clinical outcomes which are attributable to
excessive ventricular rates
Strong
Recommendation
Low Quality
Evidence
We recommend that the goals of rhythm control
therapy should be to improve patient symptoms
and clinical outcomes, and that these do not
necessarily imply the elimination of all AF
Strong
Recommendation
Moderate Quality
Evidence
Values and Preferences
These recommendations place a high value on the decision of individual patients
to balance relief of symptoms and improvement in QOL and other clinical
outcomes with the potential greater adverse effects of Class I/III antiarrhythmic
drugs compared to rate control therapy.
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2012 CCS Atrial Fibrillation Guidelines Update
Referral for Specialty Care
• Most patients with AF/AFL should be considered for referral to
a cardiologist or an internist with an interest in cardiovascular
disease for an expert opinion on management.
• Patients ≤ 35 yr old with symptomatic AF should be referred to
an arrhythmia specialist to rule out other forms of SVT that may
trigger AF and that would be best treated by radiofrequency
ablation.
• Patients who remain highly symptomatic despite multiple trials
of antiarrhythmic drug therapy, or who remain unresponsive to,
or intolerant of rate controlling therapies should be referred to
an arrhythmia specialist for an expert opinion on management
alternatives.
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
Rate or Rhythm Control?
• How do you decide if you are going to
pursue rate or rhythm control for a
patient with AF?
• No right or wrong answer
• Often, the two are simultaneous:
– Rhythm control requires good rate
control when patient goes back into AF
• Need to continuously re-evaluate the
strategy as the AF progresses
– What may have been a good initial
strategy may no longer be warranted
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2012 CCS Atrial Fibrillation Guidelines Update
Factors Influencing Decision
of Rate vs Rhythm Control
Favours Rate Control
Persistent AF
Favours Rhythm Control
Paroxysmal AF
Newly Detected AF
Less Symptomatic
More Symptomatic
> 65 years of age
< 65 years of age
Hypertension
No Hypertension
No History of Congestive
Heart Failure
Congestive Heart Failure clearly
exacerbated by AF
Previous Antiarrhythmic
Drug Failure
No Previous Antiarrhythmic
Drug Failure
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2012 CCS Atrial Fibrillation Guidelines Update
What is Optimal Target Heart Rate?
• RACE II suggested that strict rate control
(< 80 bpm at rest, < 110 bpm with activity)
was no different compared to lenient
strategy (< 110 bpm at rest)
• However, actual HR in both groups were
75 and 86 bpm respectively
• Thus, the trial was not that lenient
• Few patients had HR > 100 bpm
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2012 CCS Atrial Fibrillation Guidelines Update
Ventricular Rate Control
We recommend that ventricular rate be
assessed at rest in all patients with persistent
and permanent AF/AFL.
Strong
Recommendation
Moderate Quality
Evidence
We recommend that heart rate during exercise
be assessed in patients with persistent or
permanent AF/AFL and associated exertional
symptoms.
Strong
Recommendation
Moderate Quality
Evidence
We recommend that treatment for rate control
of persistent/permanent AF/AFL should aim for
a resting heart rate of less than 100 beats per
minute.
Strong
Recommendation
High Quality
Evidence
Values and Preferences
These recommendations place a high value on the randomized clinical trials and
other clinical studies demonstrating that ventricular rate control of AF is an
effective treatment approach for many patients with AF.
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2012 CCS Atrial Fibrillation Guidelines Update
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2012 CCS Atrial Fibrillation Guidelines Update
Ventricular Rate Control
We recommend β-blockers or nondihydropyridine calcium channel blockers as
initial therapy for rate control of AF/AFL in most
patients without a past history of MI or LV
dysfunction.
Strong
Recommendation
Moderate Quality
Evidence
We suggest that digoxin not be used as initial
therapy for active patients and be reserved for
rate control in patients who are sedentary or
who have LV systolic dysfunction.
Conditional
Recommendation
Moderate Quality
Evidence
We suggest that digoxin be added to therapy
with beta-blockers or calcium channel blockers
in patients whose heart rate remains
uncontrolled.
Conditional
Recommendation
Moderate Quality
Evidence
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2012 CCS Atrial Fibrillation Guidelines Update
Ventricular Rate Control
We recommend that dronedarone not be used in
patients with permanent AF nor for the sole purpose
of rate control.
Strong
Recommendation
High Quality
Evidence
We recommend dronedarone not be used in patients
with a history of heart failure or a left ventricular
ejection fraction ≤ 0.40.
Strong
Recommendation
Moderate Quality
Evidence
We suggest dronedarone be used with caution in
patients taking digoxin.
Conditional
Recommendation
Moderate Quality
Evidence
Values and Preferences
These recommendations recognize that the mechanism(s) for the differences between the
results of the ATHENA and the PALLAS trials have not
yet been determined. These recommendations are based on the known differences between
the 2 patient populations and are also informed by the results of the ANDROMEDA trial.
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
Recommendation
We recommend that treatment for rate
2010 CCS
control of persistent/permanent AF or
AFL should aim for a resting heart rate
Guidelines
< 100 bpm
Reasonable to initiate treatment with a
lenient rate control protocol aimed at
resting HR <110 bpm. Reasonable to
2010 ESC
adopt a stricter rate control strategy
Guidelines
when symptoms persist or
tachycardiomyopathy occurs, despite
lenient rate control: HR <80
Treatment to achieve strict rate control
of heart rate is not beneficial compared
2010
to achieving a resting heart rate < 110
ACCF/AHA/HRS
bpm in patients with persistent AF who
Focused
have stable ventricular function (LVEF >
Update
0.40) and no or acceptable symptoms
related to AF
HR <80 bpm at rest and <110 bpm
2004 CCS
during 6 min hallwalk
Guidelines
Strength /Class of
Recommendation
Level or
Quality of
Evidence
Strong
High
IIa
B
III – no benefit
B
IIa
C
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2012 CCS Atrial Fibrillation Guidelines Update
Ventricular Rate Control
Previous MI or LV Systolic Dysfunction
We recommend beta-blockers as initial therapy
for rate control of AF/AFL in patients with
myocardial infarction or left ventricular systolic
dysfunction
Strong
Recommendation
High Quality
Evidence
Values and Preferences
This recommendation places a high value on the results of multiple randomized
clinical trials reporting the benefit of beta-blockers to improve survival and
decrease the risk of recurrent myocardial infarction and prevent new-onset heart
failure following myocardial infarction as well as the adverse effects of calcium
channel blockers in the setting of heart failure.
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2012 CCS Atrial Fibrillation Guidelines Update
Ventricular Rate Control
AV Junction Ablation
We recommend AV junction ablation and
implantation of a permanent pacemaker in
symptomatic patients with uncontrolled
ventricular rates during AF despite maximally
tolerated combination pharmacologic therapy
Strong
Recommendation
Moderate Quality
Evidence
Values and Preferences
This recommendation places a high value on the results of many small
randomized trials and one systematic review reporting significant improvements
in quality of life and functional capacity as well as a decrease in hospitalizations
for AF following AV junction ablation in highly symptomatic patients.
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2012 CCS Atrial Fibrillation Guidelines Update
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
2016-03-22
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2012 CCS Atrial Fibrillation Guidelines Update
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
2016-03-22
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2012 CCS Atrial Fibrillation Guidelines Update
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2016-03-22
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2012 CCS Atrial Fibrillation Guidelines Update
Skanes AC, Healey JS et al., Can J Cardiol 2012 Mar;28(2): 125-136
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2012 CCS Atrial Fibrillation Guidelines Update
Pill in the Pocket For Rhythm Control
We recommend intermittent antiarrhythmic
drug therapy ("pill in pocket") in symptomatic
patients with infrequent, longer-lasting
episodes of AF/AFL as an alternative to daily
antiarrhythmic therapy.
Strong
Recommendation
Moderate Quality
Evidence
– Single dose flecainide (200-300 mg) or
propafenone (450-600 mg) as an oral dose
– Often prescribed with a short-acting betablocker at the same time (metoprolol 50-100 mg)
Values and preferences
This recommendation places a high value on the results of clinical studies
demonstrating the efficacy and safety of intermittent antiarrhythmic drug
therapy in selected patients.
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2012 CCS Atrial Fibrillation Guidelines Update
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2012 CCS Atrial Fibrillation Guidelines Update
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2012 CCS Atrial Fibrillation Guidelines Update
Rhythm Control Does Not
Replace Anticoagulation
• No evidence that AF reduction via antiarrhythmic
therapy reduces the risk of stroke/thromboembolism
• Patients must continue on appropriate
anticoagulation according to their individual embolic
risk (CHADS2 score)
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2012 CCS Atrial Fibrillation Guidelines Update
Cardioversion for Rhythm Control
We recommend electrical or pharmacologic
cardioversion for restoration of sinus rhythm
in patients with AF/AFL selected for rhythm
control therapy who are unlikely to convert
spontaneously.
Strong
Recommendation
Low Quality
Evidence
We recommend pre-treatment with
antiarrhythmic drugs prior to electrical
cardioversion in patients who have had AF
recurrence post-cardioversion without
antiarrhythmic drug pre-treatment.
Strong
Recommendation
Moderate Quality
Evidence
Values and preferences
These recommendations place a high value on the decision of individual
patients to pursue a rhythm control strategy for improvement in quality of
life and functional capacity.
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2012 CCS Atrial Fibrillation Guidelines Update
Pacing for Rhythm Control
We suggest that, in patients requiring pacing
for the treatment of symptomatic bradycardia
secondary to sinus node dysfunction, atrial
or dual chamber pacing be generally used for
the prevention of AF
Conditional
Recommendation
High Quality
Evidence
We suggest that, in patients with intact AV
conduction, pacemakers be programmed to
minimize ventricular pacing for prevention of
AF
Conditional
Recommendation
Moderate Quality
Evidence
Values and preferences
These recommendations recognize a potential benefit of atrial or dual
chamber pacing programmed to minimize ventricular pacing to reduce the
probability of AF development following pacemaker implantation.
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2012 CCS Atrial Fibrillation Guidelines Update
Pacing Mode and AF
Danish
Extended
Danish
AAI vs VVI
CTOPP
CTOPP
MOST
AAI vs DDD
Number
225
2568
2568
2050
177
Age (yr)
71 ± 17
73 ± 10
73 ± 10
74 (67-80)
74 ± 9
SND
All pacemaker
All pacemaker
SND
SND
patients
patients
3.1
6.4
2.7
2.9
Pacing Indication
Follow-up (yr)
Pacing Modes
AF Occurrence (%/yr)
Risk Reduction (%)
P value
5.5
AAI vs VVI AAI/R or DDD/R AAI/R or DDD/R DDDR vs VVIR
AAI vs DDDR-s
vs VVI/R
vs VVI/R
vs DDDR-l
4.1 vs 6.6
5.3 vs 6.3
4.5 vs 5.7
7.9 vs 10.0
2.4 vs 8.3 vs 6.2
46
18
20
21
73
0.012
0.05
0.009
0.008
0.02
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2012 CCS Atrial Fibrillation Guidelines Update
Canadian Cardiovascular Society Atrial
Fibrillation Guidelines 2012*: Catheter
Ablation of Atrial Fibrillation and Flutter
Atul Verma MD
Jafna L Cox MD
Laurent Macle MD
Allan C Skanes MD
*Unchanged from 2010
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2012 CCS Atrial Fibrillation Guidelines Update
Systematic Review of RCTs
Ablation vs Drug Rx
•
•
•
Ablation
28/32
Control
13/35
OR
11.85
95% CI
3.4-41.4
12/15
6/15
6.0
1.2-30.7
46/53
13/59
23.3
8.5-63.6
85/99
24/99
19.0
9.2-39.3
38/68
6/69
13.3
5.1-34.9
266/344
102/346
15.8
10.1-24.7
9 RCTs / 3 systematic reviews in 1274 patients who have failed ≥ 1 drug
uniformly demonstrate large differences in recurrence of AF
(OR 9.74 95% CI, 3.98 to 23.87) in favour of ablation vs AAD
Piccini JP et al. Circ Arrhythm 2009;2:626
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2012 CCS Atrial Fibrillation Guidelines Update
Worldwide AF Ablation (’03-’06)
Type of Complication (n=14,218)
Femoral pseudoaneurysm
AV fistulae
Pneumothorax
No of Pts
152
88
15
Rate%
0.93
0.54
0.09
Valve damage/requiring surgery
11/7
0.07
Tamponade
Transient ischemic attack
PV stenosis requiring intervention
Stroke
Permanent diaphragmatic paralysis
Death
Atrium-esophageal fistulae
213
115
48
37
28
25
3
1.31
0.71
0.29
0.23
0.17
0.15
0.02
TOTAL
741
4.54%
Cappato R et al. Circ Arrhythm Electrophysiol. 2010;3:32-8
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Recommendations Ablation
We recommend catheter ablation of AF in
patients who remain symptomatic
following adequate trials of anti-arrhythmic
drug therapy and in whom a rhythm
control strategy remains desired.
Strong Recommendation
Moderate Quality
Evidence
We suggest catheter ablation to maintain
sinus rhythm in select patients with
symptomatic AF and mild-moderate
structural heart disease who are
refractory or intolerant to at least one antiarrhythmic medication.
Conditional
Recommendation
Moderate Quality
Evidence
We suggest catheter ablation to maintain
sinus rhythm as first-line therapy for relief
of symptoms in highly selected patients
with symptomatic, paroxysmal AF.
Conditional
Recommendation
Low Quality Evidence
Values and Preferences:
These recommendations recognize that the balance of risk with ablation and benefit in symptom
relief and improvement in quality of life must be individualized. They also recognize that patients
may have relative or absolute cardiac or non-cardiac contra-indications to specific medications.
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Recommendations Ablation
We recommend curative catheter ablation for
symptomatic patients with typical atrial flutter as
first line therapy or as a reasonable alternative to
pharmacologic rhythm or rate control therapy.
Strong
Recommendation
Moderate Quality
Evidence
In patients with evidence of ventricular preexcitation during AF, we recommend catheter
ablation of the accessory pathway, especially if AF
is associated with rapid ventricular rates, syncope,
or a pathway with a short refractory period.
Strong
Recommendation
Low Quality
Evidence
In young patients with lone, paroxysmal AF, we
suggest an electrophysiological study to exclude a
reentrant tachycardia as a cause of AF; if present,
we suggest curative ablation of the tachycardia.
Conditional
Recommendation
Very Low
Quality Evidence
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2012 CCS Atrial Fibrillation Guidelines Update
Comparison of North American and European Guidelines
CCS Guidelines
ESC Guidelines
ACCF/AHA/HRS
Strength
Level of
Evidence
Class
Level of
Evidence
Class
Level of
Evidence
Paroxysmal*
Conditional
Moderate
IIa
(Conditional)
A (High)
I (Strong)¶
A (High)
Persistent*
Conditional
Moderate
IIa
(Conditional)
B
(Moderate)
IIa
(Conditional)
A (High)
Failed 1 drug
Conditional
Moderate
--
--
I (Strong)¶
A (High)
Strong
Moderate
--
--
--
--
Conditional
Low
IIb
(Conditional)
B
(Moderate)
--
--
--
--
--
--
IIb
(Conditional)
A (High)
Failed ≥ 2
drugs
1st Line
PAF / sign.
structural
heart
disease
* Applies to patients with symptomatic AF and failed at least one anti-arrhythmic drug.
¶ Dictates ablation performed in experienced centre in patient with minimal heart disease
-- Not directly addressed. Often this group is incorporated into other recommendations
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2012 CCS Atrial Fibrillation Guidelines Update
Canadian Cardiovascular Society Atrial
Fibrillation Guidelines 2012*:
Management of recent onset atrial
fibrillation and atrial flutter in the
emergency department
Ian G. Stiell, MD, MSc
Laurent Macle, MD
*Unchanged from 2010
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2012 CCS Atrial Fibrillation Guidelines Update
ED Management of Recent Onset AF/AFL
We recommend that in stable patients with
recent-onset AF/AFL, a strategy of rate
control or rhythm control could be selected
Strong
Recommendation
High Quality
Evidence
Values and Preferences
This recommendation places a high value on the randomized control
trials investigating rate control as an alternative to rhythm control for
AF/AFL, recognizing that these trials did not specifically address the
ED environment.
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2012 CCS Atrial Fibrillation Guidelines Update
Hemodynamically Unstable Patients
with AF/AFL
We recommend for patients with acute
hemodynamic instability secondary to rapid
recent-onset AF/AFL, immediate electrical
conversion to sinus rhythm
Strong
Recommendation
Low Quality
Evidence
Values and Preferences
This recommendation places a high value on the immediate management of
hemodynamic instability and a lower value on anticoagulation status under
these circumstances. It is also recognized that this is a relatively rare
circumstance and that in most cases, stroke risk and anticoagulation status
can be considered prior to immediate cardioversion.
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2012 CCS Atrial Fibrillation Guidelines Update
Electrical Cardioversion
We recommend that electrical cardioversion
may be conducted in the ED with 150-200
joules biphasic waveform as the initial
energy setting.
Strong
Recommendation
Low Quality
Evidence
Values and Preferences
This recommendation places a high value on the avoidance of
repeated shocks and the avoidance of ventricular fibrillation that
can occur with synchronized cardioversion of AF at lower energy
levels. It is recognized that the induction of VF is a rare but easily
avoidable event.
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2012 CCS Atrial Fibrillation Guidelines Update
In hemodynamically stable patients with AF/AFL of known duration
< 48 h in whom a strategy of rhythm control has been selected:
We recommend that rate-slowing agents alone are
acceptable while awaiting spontaneous conversion
Strong
Recommendation
Moderate Quality
Evidence
We recommend that synchronized electrical
cardioversion or pharmacological cardioversion may be
used when a decision is made to cardiovert patients in
the emergency department. See Tables for drug
recommendations.
Strong
Recommendation
Moderate Quality
Evidence
We suggest that antiarrhythmic drugs may be used to
pre-treat patients before electrical cardioversion in ED in
order to decrease early recurrence of AF and to enhance
cardioversion efficacy
Conditional
Recommendation
Low Quality
Evidence
Values and Preferences
These recommendations place a high value on determination of the duration of AF/AFL as a
determinant of stroke risk with cardioversion. Also, individual considerations of the patient and
treating physician are recognized in making specific decisions about method of cardioversion.
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2012 CCS Atrial Fibrillation Guidelines Update
Rate Control: IV Therapy
Drug
Dose
Risks
Diltiazem*
0.25 mg/kg IV bolus
over 10 min; repeat at
0.35 mg/kg IV
Hypertension,
bradycardia
Metoprolol
2.5-5mg IV bolus over
2 min; up to 3 doses
Hypotension,
bradycardia
Verapamil*
0.075-0.15mg/kg over 2
min
Hypotension,
bradycardia
0.25 mg IV each 2 h;
up to 1.5mg
Bradycardia,
Digitalis toxicity
Digoxin
*Calcium-channel blockers should not be used in patients with heart failure or left
ventricular dysfunction
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Pharmacologic Cardioversion
Drug
Dose
Efficacy
Risks
Class 1A
Procainamide
15-17 mg/kg IV
over 60 min
++
5% hypotension
+++
+++
Hypotension, 1:1
flutter, bradycardia
Hypotension, 1:1
flutter, bradycardia
Class IC*
Propafenone
Flecainide
Class III
Ibutilide
450-600 mg PO
300-400 mg PO
1-2 mg IV over
10-20 min
Pre-treat with
MgSO4 1-2 mg IV
++
2-3% Torsades de
pointes
*Class IC drugs should be used in combination with AV nodal blocking agents (beta-blockers or calciumchannel inhibitors). Class IC agents should also be avoided in patients with structural heart disease.
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Wolff Parkinson White Syndrome
We recommend urgent electrical cardioversion
if the patient is hemodynamically unstable
Strong
Recommendation
Low Quality
Evidence
We recommend Intravenous antiarrhythmic
agents procainamide or ibutilide in stable
patients
Strong
Recommendation
Low Quality
Evidence
We recommend that AV nodal blocking agents
(digoxin, calcium channel blockers, betablockers, adenosine) are contra-indicated.
Strong
Recommendation
Low Quality
Evidence
Values and Preferences
These recommendations place a high value on avoidance of the degeneration of pre-excited
AF to ventricular fibrillation. It is recognized that degeneration can occur spontaneously or it
can be facilitated by the administration of specific agents that in the absence of ventricular
pre-excitation would be the appropriate therapy for rate control of AF.
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2012 CCS Atrial Fibrillation Guidelines Update
CCS Atrial Fibrillation Guidelines 2012:
Prevention of Stroke and Systemic
Thromboembolism in
Atrial Fibrillation and Flutter
John A Cairns, MD, FRCPC,
Stuart Connolly, MD, FRCPC,
Gordon Gubitz, MD, FRCPC
Sean McMurtry, MD, PhD, FRCPC,
Mario Talajic, MD, FRCPC
Carl Van Walraven, MD, FRCPC, MSc
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2012 CCS Atrial Fibrillation Guidelines Update
Predictive Index for Stroke
CHADS2
Risk Factor
Score
Patients
(n = 1733)
Adjusted Stroke
Rate (%/yr) 95% CI
CHADS2
Score
120
1.9 (1.2 to 3.0)
0
Congestive Heart
Failure
1
Hypertension
1
463
2.8 (2.0 to 3.8)
1
Age ≥ 75
1
523
4.0 (3.1 to 5.1)
2
Diabetes Mellitus
1
337
5.9 (4.6 to 7.3)
3
Stroke/TIA/
Thromboembolism
2
220
8.5 (6.3 to 11.1)
4
65
12.5 (8.2 to 17.5)
5
Maximum Score
6
5
18.2 (10.5 to 27.4)
6
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Lip, GY, et al. Stroke 2010; 46: 2731
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2012 CCS Atrial Fibrillation Guidelines Update
Patients (n = 7329)
TE Rate assuming
no warfarin
CHA2DS2VASc
Score
1
0
0
422
1.3
1
1230
2.2
2
1730
3.2
3
1718
4.0
4
1159
6.7
5
679
9.8
6
294
9.6
7
82
6.7
8
14
15.2
9
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2012 CCS Atrial Fibrillation Guidelines Update
Bleeding Risk – HAS-BLED Score
Letter
Clinical Characteristic
Points
H
Hypertension
1
A
Abnormal Liver or Renal Function
1 point each
1 or 2
S
Stroke
1
B
Bleeding
1
L
Labile INRs
1
E
Elderly (age > 65 yr)
1
D
Drugs or Alcohol
1 point each
1 or 2
Maximum 9 points
Pisters R et al. Chest. 2010 Nov;138:1093-100
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RRR = 64%
Hart Ann Int Med 1999;131:492
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RRR = 19%
Hart Ann Int Med 1999;131:492
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RCTs Warfarin vs ASA
RRR=39%
50%
Warfarin Better
0
-50%
Warfarin Worse
Hart. Ann Int Med 2007;147:590
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2012 CCS Atrial Fibrillation Guidelines Update
40
40
Events/1000 patients/year
35
30
17
24
28
25
13 18
NoRx
Warfarin
Aspirin
20
15
19
10 12
10
5
0
7
11
CHADS 0
10
17
CHADS 1
14
23
CHADS 2
AF Patients: Risk of Stroke (white numbers) and of Stroke + Non-cerebral Major Bleed (black numbers)
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2012 CCS Atrial Fibrillation Guidelines Update
Cardioversion – AF ≥ 48 hr
We recommend that hemodynamically stable
patients with AF/AFL of ≥ 48 hours or
uncertain duration for whom electrical or
pharmacological cardioversion is planned
should receive OAC at therapeutic dose for 3
weeks before and at least 4 weeks post
cardioversion
Strong
Recommendation
Moderate Quality
Evidence
Following attempted cardioversion
If AF/AFL persists or recurs or if symptoms suggest that the presenting
AF/AFL has been recurrent, the patient should have antithrombotic therapy
continued indefinitely (using either OAC or aspirin as appropriate ).
If sinus rhythm is achieved and sustained for 4 weeks, the need for
ongoing antithrombotic therapy should be determined based upon the risk
of stroke and in selected cases expert consultation may be required.
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Cardioversion – AF < 48 hr
We recommend that hemodynamically stable
patients with AF/AFL of known duration < 48
hours may undergo cardioversion without
prior or subsequent anticoagulation. However,
if the patient is at particularly high risk of
stroke (e.g. mechanical valve, rheumatic heart
disease, recent stroke or TIA), cardioversion
should be delayed and the patient should
receive OAC for 3 weeks before and at least 4
weeks post cardioversion.
Strong
Recommendation
Moderate Quality
Evidence
If AF or AFL persists, recurs, or if symptoms suggest that the presenting AF/AFL
has been recurrent, antithrombotic therapy (OAC or aspirin as appropriate)
should be commenced and continued indefinitely.
If NSR is achieved and sustained for 4 weeks, the need for ongoing
antithrombotic therapy should be determined based on the risk of stroke
(CHADS2) score and in selected cases expert consultation may be required.
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Hemodynamically Unstable Patients
Emergency Cardioversion
We suggest if the AF/AFL is of known duration < 48
hr, the patient may undergo cardioversion without
prior anticoagulation. If the patient is at high risk of
stroke (e.g. mechanical valve, rheumatic heart
disease, recent stroke or TIA), the patient should
receive IV UFH or LMWH before cardioversion if
possible, or immediately thereafter and then be
converted to OAC for at least 4 weeks post
cardioversion.
Conditional
Recommendation
Moderate Quality
Evidence
If the AF/AFL is of ≥ 48 hr or uncertain duration, we
suggest the patient receive IV UFH or LMWH before
cardioversion or immediately thereafter if even a
brief delay is unacceptable. Such a patient should
then be converted to OAC for at least 4 weeks post
cardioversion.
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Cardioversion
(TEE-Guided)
We suggest that hemodynamically stable
patients with AF/AFL of duration ≥ 48 hr or
unknown, may undergo cardioversion guided
by TEE (following the protocol from the
ACUTE trial as detailed in the text).
Conditional
Recommendation
High Quality
Evidence
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2012 CCS Atrial Fibrillation Guidelines Update
Antithrombotic Therapy Peri-Procedure
If there is a very low to moderate risk of stroke (CHADS2 ≤ 2), the
patient should have their antithrombotic agent discontinued before
the procedure (aspirin or clopidogrel for 7-10 days, warfarin for 5
days if the INR was in the range 2- 3, and dabigatran ∕ rivaroxaban ∕
apixaban for 2 days). Once post procedure hemostasis is
established (about 24 hr) the antithrombotic therapy should be
reinstated.
Conditional
Recommendation
Low Quality Evidence
If there is a particularly high risk of stroke (e.g. mechanical valve,
recent stroke or TIA, rheumatic valve disease, CHADS2 ≥ 3) or of
other thromboembolism (e.g. Fontan procedure):
Conditional
Recommendation
Low Quality Evidence
a) if there is an acceptable perioperative bleeding risk (i.e. risk of
stroke outweighs risk of bleeding) the patient should have OAC
therapy continued perioperatively or have their OAC discontinued
before the procedure and be bridged with LMWH or UFH
perioperatively, or alternatively,
b) if there is a substantial risk of major and potentially problematic
bleeding (i.e. risk of bleeding and risk of stroke are both
substantial) the patient should have their OAC discontinued before
the procedure with LMWH or UFH bridging until 12-24 pre
procedure. Once post procedure hemostasis is established (about
24 hr) the OAC should be reinstated with LMWH or UFH bridging.
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Stroke Prevention in AF patients with CKD
We recommend that patients with AF who are
receiving OAC:
Have their renal function assessed at least
annually by measuring serum creatinine and
calculating eGFR.
Strong
Recommendation
Moderate Quality
Evidence
Be regularly considered for the need for
alteration of OAC drug and ∕ or dose changes
based on eGFR.
Strong
Recommendation
Moderate Quality
Evidence
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Stroke Prevention in AF patients with CKD
For antithrombotic therapy of CKD patients, therapy
should relate to eGFR as follows:
eGFR > 30 mL per minute: We recommend that such
patients receive antithrombotic therapy according to
their CHADS₂ score as detailed in recommendations
for patients with normal renal function.
Strong
Recommendation
Moderate Quality
Evidence
eGFR 15-30 mL per minute and not on dialysis: We
suggest that such patients receive antithrombotic
therapy according to their CHADS₂ score as for
patients with normal renal function. The preferred
agent for these patients is warfarin.
Conditional
Recommendation
Moderate Quality
Evidence
Values and Preferences:
This recommendation places a relatively higher value on prevention of ischemic stroke than on bleeding complications associated with antithrombotic
therapy, as well as the limited data available for new OACs in CKD patients. No therapy may be appropriate for some patients with eGFR 15-30 mL per
minute (not on dialysis), with a stronger preference for avoiding bleeding complications than preventing ischemic stroke.
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Stroke Prevention in AF patients with CKD
For antithrombotic therapy of CKD patients, therapy
should relate to eGFR as follows:
eGFR < 15 mL per minute (on dialysis): We suggest
that such patients not routinely receive either OAC or
Conditional
Recommendation
Low Quality Evidence
ASA for stroke prevention in AF.
Conditional
Recommendation
Low Quality Evidence
Values and Preferences:
This recommendation places a relatively higher weight on observational data linking warfarin and ASA use with mortality in
patients on dialysis, and relatively lower weight on the potential for these agents to prevent ischemic stroke. Therapy with OACs
or antiplatelet drugs may be appropriate for some patients with eGFR < 15 mL per minute (on dialysis) in whom there is a
stronger preference for avoiding ischemic stroke.
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Stroke Prevention in AF patients with CKD
PRACTICAL TIP:
Patients with eGFR 30-50 mL per minute need more frequent measures
of eGFR and may need OAC dose reductions with conditions that may
transiently reduce eGFR. This is especially true in the elderly (age older
than 75 years) as bleeding risk increases with age.
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Canadian Cardiovascular Society Atrial
Fibrillation Guidelines 2012*:
Prevention and treatment of atrial
fibrillation following cardiac surgery
L. Brent Mitchell MD
*Unchanged from 2010
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Post Operative AF (POAF)
COMPLICATIONS RATES – no POAF versus POAF
10
9.3
8
6.4
6
%
5.5
5.3
4.7
4
2
3.4
3.6
3.0
1.9
4.0
4.1
1.7
0
CVA
CHF
MI
PPM
VT/VF
MORT
Steinberg ed. Atrial Fibrillation after Cardiac Surgery pp37-50, 2000
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POAF Prevention
TREATMENTS WITH GOOD EVIDENCE OF EFFICACY
THERAPY
N
n
RR (95% CI)
beta-blockers
31
4452
0.36 (0.28 – 0.47)
BB withdrawal
25
2600
0.30 (0.22 – 0.40)
no BB withdrawal
3
1163
0.69 (0.54 – 0.87)
sotalol
9
1382
0.34 (0.26 – 0.45)
amiodarone
18
3296
0.48 (0.40 – 0.57)
IV magnesium
22
2896
0.54 (0.40 – 0.74)
biatrial pacing
10
754
0.44 (0.31 – 0.64)
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Relative Risk
Burgess DC et al. Eur Heart J 27:2846-57, 2006
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POAF Prevention
COMPARISONS OF TREATMENT EFFICACIES
THERAPY
N
n
RR (95% CI)
amio vs AP
1
74
0.50 (0.30 – 0.82)
BB vs magnesium
1
134
0.53 (0.36 – 0.80)
sotalol vs BB
4
900
0.50 (0.34 – 0.74)
amio vs BB
1
102
0.53 (0.37 – 0.93)
amio vs sotalol
1
160
0.77 (0.54 – 1.12)
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Relative Risk
Mitchell LB et al. Can J Cardiol 21:45B-50B, 2005
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POAF Prevention
We recommend that patients who have been
receiving a beta-blocker before cardiac surgery
have that therapy continued through the
operative procedure in the absence of the
development of a new contraindication.
Strong
Recommendation
High Quality
Evidence
We suggest that patients who have not been
receiving a beta-blocker before cardiac surgery
have beta-blocker therapy initiated just before
or immediately after the operative procedure in
the absence of a contraindication.
Conditional
Recommendation
Low Quality
Evidence
Values and Preferences: These recommendations place a high value on
reducing post-operative AF and a lower value on adverse hemodynamic
effects of beta-blockade during or after cardiac surgery. It is also noted that
inherent to a strategy of prophylaxis, a number of patients will receive betablocker therapy without personal benefit.
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POAF Prevention
We recommend that patients who have a
contra-indication to beta-blocker therapy
before or after cardiac surgery be considered
for prophylactic therapy with amiodarone to
prevent postoperative AF.
Strong
Recommendation
High Quality
Evidence
Values and Preferences: This recommendation places a high value
on minimizing the potential adverse effects of amiodarone and a
lower value on data suggesting that amiodarone is more effective
than beta-blockers for this purpose.
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POAF Prevention
We suggest that patients who have a contraindication to beta-blocker therapy and to
amiodarone therapy before or after cardiac
surgery be considered for prophylactic
therapy to prevent postoperative AF with IV
magnesium or with biatrial pacing.
Conditional
Recommendation
Low to Moderate
Quality Evidence
Values and Preferences: This recommendation places a high value on
preventing post-operative AF using more novel therapies that are supported
by lower quality data. A high value is placed on the low probability of adverse
effects from magnesium. The use of bi-atrial pacing needs to be
individualized by patient and institution, as the potential for adverse effects
may outweigh potential benefit based on local expertise.
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POAF Prevention
We suggest that patients at high risk of
postoperative AF be considered for
prophylactic therapy to prevent
postoperative AF with sotalol or combination
therapy including two or more of a betablocker, amiodarone, IV magnesium, or
biatrial pacing.
Conditional
Recommendation
Low to Moderate
Quality Evidence
Values and Preferences: This recommendation recognizes that data
confirming the superiority of combinations of prophylactic therapies is
sparse.
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Comparison - Prevention
CCS Guidelines
ESC Guidelines
Strength
LOE
Class
LOE
BB continued if on
Strong
High
I
A
BB started if not on
Cond
Low
I
A
Amio if BB contraindicated
Strong
High
IIa
A
Sotalol may be considered
Cond
Mod
IIb
A
Bi-A Pace may be considered
Cond
Low
IIb
A
IV Mag may be considered
Cond
Low
--
--
Corticosteriods considered
--
--
IIb
B
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POAF - Treatment
RCT of Rate- vs Rhythm-Control Treatment of PAOF (N=50)
1.00
96%
91%
Pts in hospital
9.0 ± 0.7 days
0.80
13.2 ± 2.0 days
0.60
p = 0.05
0.40
rhythm
0.20
rate
p = 0.27
0.00
0
5
10
15
20
25
Days Post-Op
30
35
rhythm
rate
NSR at 8 weeks
Lee JK et al. Am Heart J 2000;140:9:871-7.
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POAF - Treatment
We suggest that consideration be given to
anticoagulation therapy if post-operative
continuous atrial fibrillation persists for more
than 72 hours. This consideration will include
individualized assessment of the risks of a
thromboembolic event and the risk of postoperative bleeding.
Conditional
Recommendation
Low Quality
Evidence
Values and Preferences: This recommendation places a higher value on
minimizing the risk of thromboembolic events and a lower value on the potential
for post-operative bleeding. Because the risk of post-operative bleeding
decreases with time the benefit to risk ratio favours a longer period without
anticoagulation in the post-operative setting than that suggested in other
settings.
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2012 CCS Atrial Fibrillation Guidelines Update
POAF - Treatment
We recommend that temporary epicardial
pacing electrode wires be placed at the time
of cardiac surgery to allow backup
ventricular pacing as necessary.
Strong
Recommendation
Low Quality
Evidence
We recommend that post operative AF with a
rapid ventricular response be treated with a
beta-blocker, a non-dihydropyridine calcium
antagonist, or amiodarone to establish
ventricular rate control. The specific agent
chosen will be individualized for each patient
but a beta-blocker is usually preferred.
Strong
Recommendation
High Quality
Evidence
Values and Preferences: This recommendation places a high value on the
randomized controlled trials investigating rate control as an alternative to
rhythm control for AF, recognizing that these trials did not specifically address
the post-operative period.
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POAF - Treatment
We suggest that post operative AF may be
appropriately treated with either a ventricular
response rate-control strategy or a rhythmcontrol strategy.
Conditional
Recommendation
Low Quality
Evidence
Values and Preferences: This recommendation places a high value on the
randomized controlled trials investigating rate control as an alternative to
rhythm control for AF, recognizing that these trials did not specifically address
the post-operative period.
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POAF - Treatment
We recommend that, when anticoagulation
therapy, rate-control therapy and/or rhythmcontrol therapy has been prescribed for postoperative AF, formal reconsideration of the
ongoing need for such therapy should be
undertaken six to twelve weeks later.
Strong
Recommendation
Moderate Quality
Evidence
Values and Preferences: This recommendation reflects the high
probability that post-operative AF will be a self-limiting process that
does not require long-term therapy.
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Comparison - Treatment
CCS Guidelines
ESC Guidelines
Strength
LOE
Class
LOE
epicardial V-Pace wires at OR
Strong
Low
--
--
Rate control with BB, CA, dig
Strong
High
I
B
Rate control in that order
Strong
High
agree in text
AF control AAD considered
Cond
Low
IIa
C
anticoag considered at 72hr
Cond
Low
IIa (48hr)
A (48 hr)
consider DC Rx at 6-12 weeks
Strong
Mod
--
--
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Canadian Cardiovascular Society Atrial
Fibrillation Guidelines 2010:
Surgical Therapy
Pierre Pagé MD
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2012 CCS Atrial Fibrillation Guidelines Update
Surgical Treatment of AF
We recommend that a surgical AF ablation
procedure be undertaken in association with
mitral valve surgery in patients with AF when
there is a strong desire to maintain sinus
rhythm, the likelihood of success of the
procedure is deemed to be high, and the
additional risk is low.
Strong
Recommendation
Moderate Quality
Evidence
Values and Preferences: This recommendation recognizes
that individual institutional experience and patient considerations best
determine for whom the surgical procedure is performed.
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Surgical Treatment of AF
We recommend that patients with
asymptomatic lone AF, in whom AF is not
expected to affect cardiac outcome, should
not be considered for surgical therapy for AF.
Strong
Recommendation
Low Quality
Evidence
Values and Preferences: This recommendation recognizes that
patients with lone AF are at low risk for stroke or other adverse
cardiovascular outcomes. Thus, elimination of AF in the absence of
a high number of symptoms is unlikely to result in an improvement in
quality of life.
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Surgical Treatment of AF
In patients with AF who are undergoing aortic
valve surgery or coronary artery bypass
surgery, we suggest that a surgical AF
ablation procedure be undertaken when there
is a strong desire to maintain sinus rhythm,
the success of the procedure is deemed to be
high, and the additional risk low .
Conditional
Recommendation
Low Quality
Evidence
Values and Preferences: This recommendation recognizes that left
atrial endocardial access is not routinely required for aortic or coronary
surgery. This limits ablation to newer epicardial approaches.
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Surgical Treatment of AF
We recommend that closure (excision or
obliteration) of the left atrial appendage be
undertaken as part of the surgical ablation of
AF associated with mitral valve surgery.
Strong
Recommendation
Low Quality
Evidence
We suggest that closure of the left atrial
Conditional
appendage be undertaken as part of the
Recommendation
surgical ablation of persistent AF in patients
Low Quality
undergoing aortic valve surgery or coronary
Evidence
artery bypass surgery if this does not
increase the risk of the surgery.
Values and Preferences: These recommendations place a high
value on stroke reduction and a lower value on any concomitant loss
of atrial transport with left atrial appendage closure.
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Surgical Treatment of AF
We recommend that oral anticoagulant
therapy be continued following surgical AF
ablation in patients with a CHADS2 score ≥ 2.
Strong
Recommendation
Moderate Quality
Evidence
We suggest that oral anticoagulant therapy be
continued following surgical AF ablation in
patients who have undergone mechanical or
bioprosthetic mitral valve replacement.
Conditional
Recommendation
Low Quality
Evidence
Values and Preferences: These recommendations place a high
value on minimizing the risk of stroke and a lower value in the utility
of long-term monitoring to document the absence of AF.
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Cox MAZE III Ablation Pattern
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Recommended Type-specific
Surgical Strategies*
Cardiac status or
type of AF
Paroxysmal
Persistent, mixed or
continuous
PVI
PVI +
Mitral Valve surgery
PVI +
Bi-atrial full Cox MAZE
or PVI +
Aortic valve / CABG
surgery
PVI
PVI +
Lone AF
PVI + is PVI plus connecting lesions to LAA and mitral valve
* All procedures must include exclusion or resection of the left atrial appendage
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Thank you and questions
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