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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EMultiple organizations have published clinical practice guidelines that recommend strategies for the management of atrial fibrillation (AF) in the clinic. This article presents various clinical practice recommendations for rate control in AF. Also discussed are the recommendations for antiarrhythmic therapy in AF, recommendations for antithrombotic therapy in AF, tools and techniques used in cryoballoon ablation of pulmonary veins, duty cycled radiofrequency ablation tools and techniques, as well as information about laser ablation.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Guidelines\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EMultiple organizations have published clinical practice guidelines that recommend strategies for the management of atrial fibrillation (AF) in the clinic. Anne M Gillis, MD, University of Calgary, Calgary, Alberta, Canada, presented various clinical practice recommendations for rate control in AF. The treatment goals for AF include ventricular rate and rhythm control, which should ultimately improve symptoms and patient outcomes [Gillis AM et al. \u003Cem\u003ECan J Cardiol\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe Canadian Cardiovascular Society (CCS) Guidelines recommend that ventricular rate be assessed at rest and during exercise in all patients and that treatment should aim to maintain a resting heart rate of \u2264100 bpm [Gillis AM et al. \u003Cem\u003ECan J Cardiol\u003C\/em\u003E 2011]. The 2011 American College of Cardiology Foundation (ACCF)\/American Heart Association (AHA)\/Heart Rhythm Society (HRS) Guidelines state that aggressive rate control is not beneficial compared with a less aggressive strategy, particularly in patients with persistent AF with stable ventricular function [Anderson JL et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2013]. Patients that have uncontrollable ventricular rates during AF despite pharmacologic treatment are recommended to receive atrioventricular junction ablation with implantation of a pacemaker [Gillis AM et al. \u003Cem\u003ECan J Cardiol\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EJohn Camm, MD, St George\u0027s University, London, United Kingdom, presented the recommendations for antiarrhythmic therapy in AF. The European Heart Rhythm Association (EHRA) updated its guidelines in 2012, which addresses the use of pharmacological cardioversion with vernakalant and the use of oral antiarrhythmic therapy [Camm AJ et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012]. Vernakalant is an ion channel blocker that specifically targets the atria with little hemodynamic adverse effects [Fedida D et al. \u003Cem\u003EJ Cardivasc Electrophysiol\u003C\/em\u003E 2005]. In several clinical trials, the mean time to cardioversion was 8 to 14 minutes, with 75% to 80% of patients converted, following the first dose of vernakalant. Prof. Camm pointed out that treatment with vernakalant is associated with a greater risk of hypotension and ventricular arrhythmia, particularly in patients with congestive heart failure (CHF) [Kynapid NDA 22\u2013034 Astellas Pharm US, Inc]. With these data, the EHRA Class I recommendations are to use pharmacologic cardioversion with intravenous flecainide, propanfenone, ibutilide, or vernakalant if there is little or no structural heart disease present [Camm AJ et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012]. Class IIb recommendations suggest that patients with moderate structural heart disease and AF for \u0026lt;7 days may receive intravenous vernakalant and in postoperative AF \u22643 days following cardiac surgery.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EThe EHRA Guidelines recommend the use of dronedarone in patients with recurrent AF for the maintenance of sinus rhythm, but do not recommend it in patients with permanent AF [Camm AJ et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012]. The 2012 update to the ACCF\/AHA\/HRS guidelines indicates that dronedarone can be used to decrease the need for hospitalization as a result of cardiovascular events in patients with paroxysmal AF or for persistent AF following cardioversion, but should not be given to patients with Class IV heart failure [Wann LS et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2011].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EThe ESC Guidelines recommend that dronedarone should not be used in Class II or Class IV heart failure and only used with caution and as a last resort in mild to moderate heart failure or in patients with left ventricular systolic dysfunction [Camm AJ et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EHugh Calkins, MD, Johns Hopkins University, Baltimore, Maryland, USA, describe the current recommendations for catheter ablation in AF. In the 2012 update to the HRS\/EHRA\/European Cardiac Arrhythmia Society (ECAS) Guidelines on catheter and surgical ablation of AF, indications for catheter ablation were identified as symptomatic AF that is refractory or intolerant to at least one Class 1 or 3 antiarrhythmic therapy and in symptomatic AF before beginning antiarrhythmic therapy with a Class 1 or 3 drug [Calkins H et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2012]. Prior to or immediately after the ablation procedure, heparin should be given, unless the patient already receives warfarin.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EThe 2012 update of the ESC Guidelines for catheter ablation indicates that, due to new data, catheter ablation can be recommended as first-line therapy for rhythm control in selected patients with AF [Camm AJ et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012]. Anticoagulant therapy is also recommended before or after an ablation procedure to reduce thromboembolic risk.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EGregory YH Lip, MD, University of Birmingham, Birmingham, United Kingdom, discussed the recommendations for antithrombotic therapy in AF. The 2012 recommendations of the American College of Chest Physicians (ACCP) suggest the use of oral anticoagulant therapy in patients with an CHADS\u003Csub\u003E2\u003C\/sub\u003E score of \u22651, and where oral anticoagulant therapy is indicated, then dabigatran 150 mg twice daily could be considered (Grade IIb) [You JJ et al. \u003Cem\u003EChest\u003C\/em\u003E 2012]. In those with a CHADS\u003Csub\u003E2\u003C\/sub\u003E score=0, other risk factors such as age 65 to 74 years, vascular disease and female gender may indicate the need for oral anticoagulation. In the absence of all risk factors, no antithrombotic therapy is recommended. The 2012 update by the CCS recommends oral anticoagulant therapy, preferably with dabigatran or rivaroxaban in patients at intermediate to high risk [Skanes AC et al. \u003Cem\u003ECan J Cardiol\u003C\/em\u003E 2012]. In patients at low risk, no antithrombotic therapy is recommended, but with \u22651 stroke risk factors, oral anticoagulant therapy may also be considered. The ESC 2012 update for the management of AF strongly recommends that physicians focus on identifying \u201ctruly low-risk\u201d patients with AF (age \u0026lt;65 years and lone AF [including females] or a CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score=0) as the first decision step, rather than focusing on patients at high risk [Camm AJ et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012]. The CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score is the only stroke risk score recommended in the ESC 2012 guideline. Patients with a CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score of \u22652 should receive anticoagulant therapy (Class I recommendation), preferably with dabigatran, rivaroxaban, or apixaban. Oral anticoagulant therapy should be considered in patients with a CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score=1 (Class IIa), with the exception of females who have a score=1 only on basis of their gender.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EThomas Neumann, MD, Kerckhoff Heart Center, Bad Nauheim, Germany, presented tools and techniques used in cryoballoon ablation of pulmonary veins. A circular mapping catheter with 8 electrodes can be introduced through the inner lumen of the shaft of cryoballoon catheter (Achieve catheter). A second generation of cryoballoon, called Arctic Front Advanced is an improvement over the previous generation (Arctic Front) because it provides more uniform and distal cooling and has an increased refrigerant flow. A single-center, nonrandomized study compared 30 patients treated with the 28-mm Arctic Front with a 300-second application with 30 patients treated with the 28-mm Arctic Front Advanced with a 240-second application time [F\u00fcrnkranz A et al. \u003Cem\u003EJ Cardiovasc Electrophysiol\u003C\/em\u003E 2013]. After the first 3 months following ablation, 37% of patients treated with Arctic Front and 13% of patients treated with Arctic Front Advanced experienced early AF recurrence. In addition, AF-free survival was greater in patients treated with Arctic Front Advanced compared with patients treated with Arctic Front (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EProf. Neumann explained several techniques that can be used with cryoballoon ablation, including hockey stick positioning, big loop positioning, inversed C-position, pull down maneuvers, and cross talk. Complications of cryoballoon therapy include phrenic nerve palsy, esophageal thermal lesions, and atrioesophageal fistula. However, Prof. Neumann suggested that some techniques may help prevent these complications.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EFrank Halimi, MD, Hospital Priv\u00e9 Parly 2, Le Chesnay, France, discussed duty cycled radiofrequency ablation tools, techniques, and suggestions for preventing complications. The pulmonary vein ablation catheter (PVAC) is 25 mm with 10 electrodes of 3 mm length spaced 3 mm apart. The PVAC can have a single or multiple arrays. The PVAC user determines the energy mode, which can be unipolar or bipolar only, or various mixtures of both. Prof. Halimi highlighted that imaging is important to understand the patient\u0027s anatomy, which is critical in preventing complications such as right phrenic nerve injury.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/24\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022AF-Free Survival Following Treatment With Cryoballoon Ablation\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-603580992\u0022 data-figure-caption=\u0022AF-Free Survival Following Treatment With Cryoballoon Ablation\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/24\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/24\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/12\/24\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13613\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003EAF-Free Survival Following Treatment With Cryoballoon Ablation\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-14\u0022\u003EIn the TTOP-AF trial [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00514735\u0026amp;atom=%2Fspmdc%2F13%2F12%2F24.atom\u0022\u003ENCT00514735\u003C\/a\u003E], 210 patients with persistent AF were randomized to receive medical management or cryoballoon ablation. At 6-month follow-up, 55.8% of patients treated with ablation were off pharmacologic therapy compared with 26.4% in the medical-management arm. The complication rate was 12.3% in the cryoballoon ablation arm and included 4 acute strokes, 1 stroke, and 6 pulmonary vein stenosis. Prof. Halimi pointed out that asymptomatic cerebral embolism is an issue with this technology, but suggested that the risk may be reduced with procedural changes.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EPetr Neuzil, MD, PhD, Na Homolce Hospital, Prague, Czech Republic, presented information about laser ablation. This technology is visually guided with a compliant balloon with nine different sizes. In an international, multicenter, open-label study of 200 patients treated with visually guided laser ablation, 98.8% of pulmonary veins were isolated, with 79.4% isolated on the first attempt [Dukkipati SR et al. \u003Cem\u003ECirc Arrhythm Electrophysiol\u003C\/em\u003E 2013]. Complications included phrenic nerve injury in 2.5% of patients, cardiac tamponade in 2% of patients, major bleeding in 1.5% of patients, and minor bleeding in 3.5% of patients.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EMultiple organizations in Europe and the United States have recently updated their clinical practice guidelines for the management of AF. Although there is a large amount of similarity across the guidelines, there are some areas that slightly differ in recommendations.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/12\/24.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nznqbe\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznqbe\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}