Ablation of Atrial Fibrillation and Atrial Tachycardia

  • Vishal LutherEmail author
  • George Katritsis


Ablation for atrial fibrillation has now become the most common procedure performed in the electrophysiology laboratory. This chapter begins by exploring the clinical significance and pathogenesis of Atrial Fibrillation and reviews its ablative approaches and potential complications. One of the most common reasons for redo-ablation is for post AF Atrial Tachycardia, and this chapter will review their mechanisms, and some of the latest approaches to their 3D mapping.


Atrial fibrillation Atrial tachycardia Mapping Ablation Pulmonary vein isolation Radiofrequency Cryoballoon Ripple mapping Local activation time Voltage Bipolar electrograms 



Atrial Fibrillation


Autonomic Nervous System


Atrial Tachycardia


Complex Fractionated Atrial Electrograms


Computed Tomography




Ejection Fraction




Ganglionated Plexi


High Frequency Stimulation


Heart Rate


Left Atrium


Left Atrial Appendage


Local Activation Time


Left Ventricle


Magnetic Resonance Imaging


Pulmonary Vein


Pulmonary Vein Isolation


Right atrium




Superior Vena Cava


Transoesophageal echocardiogram


Wide area circumferential ablation


Window of Interest


  1. 1.
    January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the american college of cardiology/american heart association task force on clinical practice guidelines and the heart rhythm society. Heart Rhythm. 2019.Google Scholar
  2. 2.
    Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016;18(11):1609–78.PubMedCrossRefGoogle Scholar
  3. 3.
    Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study. Circulation. 2014;129(8):837–47.PubMedCrossRefGoogle Scholar
  4. 4.
    Andersson T, Magnuson A, Bryngelsson IL, et al. All-cause mortality in 272,186 patients hospitalized with incident atrial fibrillation 1995–2008: a Swedish nationwide long-term case-control study. Eur Heart J. 2013;34(14):1061–7.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Wijesurendra RS, Liu A, Eichhorn C, et al. Lone atrial fibrillation is associated with impaired left ventricular energetics that persists despite successful catheter ablation. Circulation. 2016;134(15):1068–81.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Nerheim P, Birger-Botkin S, Piracha L, Olshansky B. Heart failure and sudden death in patients with tachycardia-induced cardiomyopathy and recurrent tachycardia. Circulation. 2004;110(3):247–52.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke. 1991;22(8):983–8.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Aspberg S, Chang Y, Atterman A, Bottai M, Go AS, Singer DE. Comparison of the ATRIA, CHADS2, and CHA2DS2-VASc stroke risk scores in predicting ischaemic stroke in a large Swedish cohort of patients with atrial fibrillation. Eur Heart J. 2016;37(42):3203–10.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Corley SD, Epstein AE, DiMarco JP, et al. Relationships between sinus rhythm, treatment, and survival in the atrial fibrillation follow-up investigation of rhythm management (AFFIRM) study. Circulation. 2004;109(12):1509–13.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347(23):1825–33.CrossRefGoogle Scholar
  11. 11.
    Van Gelder IC, Hagens VE, Bosker HA, et al. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med. 2002;347(23):1834–40.CrossRefGoogle Scholar
  12. 12.
    Ogawa S, Yamashita T, Yamazaki T, et al. Optimal treatment strategy for patients with paroxysmal atrial fibrillation: J-RHYTHM study. Circ J. 2009;73(2):242–8.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation—pharmacological Intervention in atrial fibrillation (PIAF): a randomised trial. Lancet. 2000;356(9244):1789–94.CrossRefGoogle Scholar
  14. 14.
    Siontis KC, Ioannidis JPA, Katritsis GD, et al. Radiofrequency ablation versus antiarrhythmic drug therapy for atrial fibrillation: meta-analysis of quality of life, morbidity, and mortality. JACC Clin Electrophysiol. 2016;2(2):170–80.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Marrouche NF, Brachmann J, Andresen D, et al. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med. 2018;378(5):417–27.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339(10):659–66.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Pappone C, Rosanio S, Oreto G, et al. Circumferential radiofrequency ablation of pulmonary vein ostia: a new anatomic approach for curing atrial fibrillation. Circulation. 2000;102(21):2619–28.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Sundt TM 3rd, Camillo CJ, Cox JL. The maze procedure for cure of atrial fibrillation. Cardiol Clin. 1997;15(4):739–48.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Hamabe A, Okuyama Y, Miyauchi Y, et al. Correlation between anatomy and electrical activation in canine pulmonary veins. Circulation. 2003;107(11):1550–5.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Kumagai K, Ogawa M, Noguchi H, Yasuda T, Nakashima H, Saku K. Electrophysiologic properties of pulmonary veins assessed using a multielectrode basket catheter. J Am Coll Cardiol. 2004;43(12):2281–9.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Wijffels MC, Kirchhof CJ, Dorland R, Allessie MA. Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation. 1995;92(7):1954–68.CrossRefGoogle Scholar
  22. 22.
    Moe GK, Abildskov JA. Atrial fibrillation as a self-sustaining arrhythmia independent of focal discharge. Am Heart J. 1959;58(1):59–70.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Moe GK, Rheinboldt WC, Abildskov JA. A computer model of atrial fibrillation. Am Heart J. 1964;67:200–20.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Calkins H, Reynolds MR, Spector P, et al. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses. Circ Arrhythm Electrophysiol. 2009;2(4):349–61.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Nielsen JC, Johannessen A, Raatikainen P, et al. Long-term efficacy of catheter ablation as first-line therapy for paroxysmal atrial fibrillation: 5-year outcome in a randomised clinical trial. Heart. 2017;103(5):368–76.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Morillo CA, Verma A, Connolly SJ, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. JAMA. 2014;311(7):692–700.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Mont L, Bisbal F, Hernandez-Madrid A, et al. Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study). Eur Heart J. 2014;35(8):501–7.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Packer DL, Mark DB, Robb RA, et al. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA. 2019.Google Scholar
  29. 29.
    Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary. J Arrhythm. 2017;33(5):369–409.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Jiang RH, Po SS, Tung R, et al. Incidence of pulmonary vein conduction recovery in patients without clinical recurrence after ablation of paroxysmal atrial fibrillation: mechanistic implications. Heart Rhythm. 2014;11(6):969–76.CrossRefGoogle Scholar
  31. 31.
    Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3(1):32–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Andrade JG, Khairy P, Macle L, et al. Incidence and significance of early recurrences of atrial fibrillation after cryoballoon ablation: insights from the multicenter sustained treatment of paroxysmal atrial fibrillation (STOP AF) trial. Circ Arrhythm Electrophysiol. 2014;7(1):69–75.PubMedCrossRefGoogle Scholar
  33. 33.
    Kuck KH, Brugada J, Furnkranz A, et al. Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation. N Engl J Med. 2016;374(23):2235–45.PubMedCrossRefGoogle Scholar
  34. 34.
    Dallaglio PD, Betts TR, Ginks M, Bashir Y, Anguera I, Rajappan K. The role of adenosine in pulmonary vein isolation: a critical review. Cardiol Res Pract. 2016;2016:8632509.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Deneke T, Jais P, Scaglione M, et al. Silent cerebral events/lesions related to atrial fibrillation ablation: a clinical review. J Cardiovasc Electrophysiol. 2015;26(4):455–63.PubMedCrossRefGoogle Scholar
  36. 36.
    Wazni OM, Beheiry S, Fahmy T, et al. Atrial fibrillation ablation in patients with therapeutic international normalized ratio: comparison of strategies of anticoagulation management in the periprocedural period. Circulation. 2007;116(22):2531–4.PubMedCrossRefGoogle Scholar
  37. 37.
    Deshmukh A, Patel NJ, Pant S, et al. In-hospital complications associated with catheter ablation of atrial fibrillation in the United States between 2000 and 2010: analysis of 93 801 procedures. Circulation. 2013;128(19):2104–12.PubMedCrossRefGoogle Scholar
  38. 38.
    Ghia KK, Chugh A, Good E, et al. A nationwide survey on the prevalence of atrioesophageal fistula after left atrial radiofrequency catheter ablation. J Interv Card Electrophysiol. 2009;24(1):33–6.PubMedCrossRefGoogle Scholar
  39. 39.
    Verma A, Jiang CY, Betts TR, et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med. 2015;372(19):1812–22.CrossRefGoogle Scholar
  40. 40.
    Chen SA, Tai CT. Catheter ablation of atrial fibrillation originating from the non-pulmonary vein foci. J Cardiovasc Electrophysiol. 2005;16(2):229–32.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Fassini G, Riva S, Chiodelli R, et al. Left mitral isthmus ablation associated with PV Isolation: long-term results of a prospective randomized study. J Cardiovasc Electrophysiol. 2005;16(11):1150–6.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Kottkamp H, Berg J, Bender R, Rieger A, Schreiber D. Box isolation of fibrotic areas (BIFA): a patient-tailored substrate modification approach for ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2016;27(1):22–30.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Nademanee K, McKenzie J, Kosar E, et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol. 2004;43(11):2044–53.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Pokushalov E, Romanov A, Katritsis DG, et al. Ganglionated plexus ablation vs linear ablation in patients undergoing pulmonary vein isolation for persistent/long-standing persistent atrial fibrillation: a randomized comparison. Heart Rhythm. 2013;10(9):1280–6.CrossRefGoogle Scholar
  45. 45.
    Rappel WJ, Narayan SM. Theoretical considerations for mapping activation in human cardiac fibrillation. Chaos. 2013;23(2):023113.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Gianni C, Mohanty S, Di Biase L, et al. Acute and early outcomes of focal impulse and rotor modulation (FIRM)-guided rotors-only ablation in patients with nonparoxysmal atrial fibrillation. Heart Rhythm. 2016;13(4):830–5.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Jais P, Matsuo S, Knecht S, et al. A deductive mapping strategy for atrial tachycardia following atrial fibrillation ablation: importance of localized reentry. J Cardiovasc Electrophysiol. 2009;20(5):480–91.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Zhang XD, Gu J, Jiang WF, et al. Optimal rhythm-control strategy for recurrent atrial tachycardia after catheter ablation of persistent atrial fibrillation: a randomized clinical trial. Eur Heart J. 2014;35(20):1327–34.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Del Carpio Munoz F, Buescher TL, Asirvatham SJ. Three-dimensional mapping of cardiac arrhythmias: what do the colors really mean? Circ Arrhythm Electrophysiol. 2010;3(6):e6–11.Google Scholar
  50. 50.
    Liuba I, Walfridsson H. Activation mapping of focal atrial tachycardia: the impact of the method for estimating activation time. J Interv Card Electrophysiol. 2009;26(3):169–80.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    De Ponti R, Verlato R, Bertaglia E, et al. Treatment of macro-re-entrant atrial tachycardia based on electroanatomic mapping: identification and ablation of the mid-diastolic isthmus. Europace. 2007;9(7):449–57.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Jamil-Copley S, Linton N, Koa-Wing M, et al. Application of ripple mapping with an electroanatomic mapping system for diagnosis of atrial tachycardias. J Cardiovasc Electrophysiol. 2013;24(12):1361–9.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Linton NW, Koa-Wing M, Francis DP, et al. Cardiac ripple mapping: a novel three-dimensional visualization method for use with electroanatomic mapping of cardiac arrhythmias. Heart Rhythm. 2009;6(12):1754–62.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Luther V, Linton NW, Koa-Wing M, et al. A prospective study of ripple mapping in atrial tachycardias: a novel approach to interpreting activation in low-voltage areas. Circ Arrhythm Electrophysiol. 2016;9(1):e003582.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Luther V, Cortez-Dias N, Carpinteiro L, et al. Ripple mapping: initial multicenter experience of an intuitive approach to overcoming the limitations of 3D activation mapping. J Cardiovasc Electrophysiol. 2017;28(11):1285–94.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Luther V, Qureshi N, Lim PB, et al. Isthmus sites identified by ripple mapping are usually anatomically stable: a novel method to guide atrial substrate ablation? J Cardiovasc Electrophysiol. 2018;29(3):404–11.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Luther V, Agarwal S, Chow A et al. Ripple-AT study. Circ Arrhythm Electrophysiol. 2019;12(8):e007394.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of CardiologyImperial College Healthcare NHS TrustLondonUK
  2. 2.National Heart and Lung Institute, Imperial College LondonLondonUK

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