Catheter Ablation of Atrial Fibrillation: Current and Evolving Indications

Catheter ablation (CA) was developed as a potentially curative procedure through electrical isolation of the pulmonary veins to isolate the main triggers of atrial fibrillation (AF). When successful, CA has clearly been shown to decrease AF recurrence and symptoms, and improve quality of life. With advancing technology, increased procedural success, and lower complication risk, CA is being used at much higher rates, with broader indications and in a diverse AF population. Symptomatic paroxysmal AF that is refractory to antiarrhythmic drugs is currently the indication for CA with the best evidence. CA for AF as first-line therapy is reserved for highly selected symptomatic patients with paroxysmal AF. Current studies have not shown an improvement in mortality or quality of life with CA as first-line therapy. In patients with persistent AF who are symptomatic despite medical therapy, CA is a reasonable therapeutic option. Although recent trials have suggested that CA reduced mortality and hospitalizations in patients with heart failure and reduced ejection fraction, the evidence is not conclusive. Therefore, current guidelines recommend CA for similar indications to patients without heart failure, but large trials comparing CA with strict rate control will be reported in the near future. Ongoing studies will assess whether CA of AF reduces major adverse cardiovascular events and whether stopping anticoagulation in the long term is possible after CA. The purpose of this review is to outline the current and evolving indications for CA of AF and the underlying evidence supporting these indications.