| Surgery Section - Transcatheter Radiofrequency
Ablation of Arrhythmogenic Foci in the Pulmonary
Veins as a Treatment for Atrial Fibrillation
| Topic: Transcatheter
Radiofrequency Ablation of Arrhythmogenic Foci
in the Pulmonary Veins as a Treatment for Atrial
Fibrillation |
Date of Origin: 10/05/2004 |
| Section: Surgery |
Policy No: 138 |
| Approved Date: 04/13/2010 |
Effective Date: 04/14/2010 |
| Next Review Date: 04/2011 |
|
| |
IMPORTANT REMINDER
Regence Medical Policies are developed to provide guidance for members and providers regarding
coverage in accordance with contract terms. Benefit determinations are based in all cases on
the applicable contract language. To the extent there may be any conflict between the Medical
Policy and contract language, the contract language takes precedence.
PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that
are considered investigational or cosmetic. Providers may bill members for services or
procedures that are considered investigational or cosmetic. Providers are encouraged to inform
members before rendering such services that the members are likely to be financially responsible
for the cost of these services.
Description
Transcatheter ablation in the atrium of the heart
and the pulmonary veins is performed to interrupt the
pathways along which abnormal electrical impulses travel.
Many of the arrhythmogenic foci, triggers of abnormal
electrical impulses, come from the tissues within the
pulmonary veins. The impulses spread across the atrium,
interfering with normal heart rhythm.
In atrial fibrillation (AF) the contractions of the
atrium are rapid, chaotic and ineffective and may cause
dizziness, fatigue and the development of blood clots
that may lead to stroke. AF can be subdivided
into paroxysmal (episodes that last fewer than seven
days and are self-terminating), persistent (episodes
that last for more than seven days and can be terminated
pharmacologically or by electrical cardioversion),
or permanent. The goals of treatment of AF are
to relieve symptoms and to decrease the risk of formation
of blood clots.
Unlike conservative treatments for AF such as medications
and cardioversion, ablation is intended to be curative.
Three basic ablation strategies that target the arrhythmogenic
foci in the pulmonary veins have emerged:
- Focal ablation inside the pulmonary veins
- Segmental ablation of the ostia of the pulmonary
veins
- Circumferential ablation of the atrial wall outside
the ostia of the pulmonary veins
| Antiarrhythmic
Medications |
Class/Mechanism |
Medication
examples |
Class Ia Sodium channel blockers |
- Disopyramide
- Procainamide
- Quinidine
|
Class Ib Sodium channel blockers |
- Lidocaine
- Mexiletine
- Phenytoin
|
Class Ic Sodium channel blockers |
- Flecainide
- Moricizine
- Propafenone
|
Class II Beta blockers |
- Atenolol
- Esmolol
- Metoprolol
- Propranolol
- Sotalol (also a K+ channel blocker)
- Timolol
|
Class III Potassium channel blockers |
- Amiodarone
- Dofetilide
- Ibutilide
- Sotalol (also a beta blocker)
|
Class IV Calcium channel blockers |
|
Class V Other or unknown mechanisms |
|
Note: This policy is not intended
to address intracardiac atrial ablation for supraventricular
tachycardia caused by arrhythmogenic foci other than
those within pulmonary veins or ablation techniques
other than radiofrequency.
Policy/Criteria
- Transcatheter radiofrequency ablation
of the pulmonary veins as a treatment for atrial
fibrillation may be considered medically necessary
when at least one of the following criteria are met:
- As an alternative to continued medical
management for patients with symptomatic paroxysmal
or persistent atrial fibrillation who have failed
or could not tolerate antiarrhythmic medications
Symptomatic is defined as impaired ability to complete
activities of daily living or essential job related
activities due to atrial fibrillation despite treatment
to control rate. Symptoms (e.g., intermittent
mild dizziness) that do not significantly impact
the patient’s functional level do not meet
this definition.
- As an alternative to AV nodal ablation and
pacemaker insertion for patients with class II
or III congestive heart failure and symptomatic
atrial fibrillation in whom heart rate is poorly
controlled by standard medications
- Up to two repeat ablations may be considered medically
necessary in patients with recurrence of atrial fibrillation
and/or development of atrial flutter following the
initial ablation procedure.
- Transcatheter radiofrequency ablation for arrhythmogenic
foci in the pulmonary veins is considered investigational
for all other indications, including but not limited
to ablation as first-line treatment of atrial fibrillation.
Scientific Background
The most important clinical outcome measures in clinical
trials for the treatment of atrial fibrillation (AF)
are [1]:
- Mortality and morbidity (e.g., cardiovascular mortality,
stroke, and congestive heart failure); however, these
are uncommon events, and currently available trials
are not powered to detect differences in these outcomes.
- Quality of life (e.g., symptoms such as reduced
exercise tolerance or hypotension that significantly
reduce the patient’s daily functional levels)
- Recurrence of AF
Recurrence of AF is a more problematic outcome measure,
since the intermittent and often transient nature of
recurrences makes accurate measurement difficult. [2] This
outcome measure has been reported in different ways.
For example, the proportion of patients in sinus rhythm
at the end of the study, the time to first recurrence,
and the number of recurrences within a time period
have been reported. A recent publication by Shemin
and colleagues highlighted the difficulties in measuring
AF recurrence and recommended a measure of AF “burden”,
defined as the percentage of time an individual is
in AF, as the optimal measure of treatment efficacy.
However, this parameter requires continuous monitoring
over a relatively long period of time, which is inconvenient
for patients, resource intensive and usually not pragmatic
in patients who do not already have an implanted pacemaker.
Recommendations for outcome assessment in trials of
atrial fibrillation treatment were included in the
2006 American College of Cardiology/American Heart
Association practice guidelines for the treatment of
atrial fibrillation. [3] These guidelines pointed out
that the appropriate end points for evaluation of treatment
efficacy in patients with paroxysmal and persistent
AF have little in common. For example, in studies of
persistent AF, the proportion of patients in sinus
rhythm at the end of follow-up is a useful end point,
but this is a less useful measure in studies of paroxysmal
AF. Given all these variables, ideally, controlled
clinical trials would report a range of outcomes (including
quality of life) and complications in homogeneous patient
groups and compared to treatment alternatives, such
as pharmacologic therapy, defibrillator therapy, and
AV nodal ablation, depending on the classification
of AF (paroxysmal, persistent, or permanent).
Underlying these issues in outcome measurement is
the ongoing controversy regarding the relative benefits
of rhythm versus rate control. Randomized trials of
pharmacologic therapies have not demonstrated the superiority
of rhythm versus rate control. [4-6] However,
the apparent equivalency of these two strategies with
pharmacologic therapy cannot be extrapolated to the
rhythm control achieved with ablation. Antiarrhythmic
medications used for rhythm control are only partially
effective, and have serious complications, including
proarrhythmic properties that can be lethal. Therefore,
nonpharmacologic strategies for rhythm control have
the potential to achieve superior outcomes than have
been seen with pharmacologic strategies.
This policy is currently based on a 2008 TEC Assessment.
[7] Six randomized, controlled trials
met the inclusion criteria for this TEC Assessment.
[8-13] The trials differed in their
patient populations, the specific catheter ablation
techniques used, and the comparisons made. The trials
addressed three distinct indications for catheter ablation:
1) patients with paroxysmal atrial fibrillation, as
a first-line treatment option (n=1 trial [9]); 2) patients
with symptomatic paroxysmal or persistent atrial fibrillation
who have failed treatment with antiarrhythmic drugs
(n=4 trials [8,10-12]); and 3) patients with symptomatic
atrial fibrillation and congestive heart failure who
have failed treatment with standard medications for
rate control and who would otherwise be considered
for AV nodal ablation and pacemaker insertion (n=1
trial [13]).
All six trials reported that maintenance of sinus
rhythm was improved for the catheter ablation group.
Recurrence rates of atrial fibrillation at one year
ranged from 11–44% for the catheter ablation
groups in these trials, compared with 63–96%
for the medication groups. Four of the six trials reported
quality of life (QOL) outcomes. One of these [8] only
reported within-group comparisons, as opposed to between-group
comparisons. The other three trials [9,12,13] reported
improvements in QOL associated with catheter ablation.
These QOL measures were self-reported, and since both
trials were unblinded, there is the possibility of
reporting bias due to placebo effect.
None of the available trials reported meaningful data
on cardiovascular morbidity and mortality associated
with atrial fibrillation. Larger randomized, controlled
trials, such as the ongoing CABANA trial (ClinicalTrials.gov
identifier NCT00578617[14]) with expected completion
in 2011, are necessary in order to determine whether
catheter ablation leads to improvements in these important
clinical outcomes. At present, any conclusions made
must be based primarily on the outcome of atrial fibrillation
recurrence, supplemented by a smaller amount of evidence
on quality of life and physiologic parameters.
The TEC Assessment concluded that catheter ablation
catheter ablation is more effective than medications
in maintaining sinus rhythm across a wide spectrum
of patients with atrial fibrillation, and across different
variations of catheter ablation. The evidence on QOL
was suggestive of a benefit for patients undergoing
catheter ablation, but not definitive. For other outcomes,
the evidence did not permit conclusions. It was not
possible to estimate the rate of serious complications,
such as pulmonary vein stenosis, cardiac tamponade,
or atrio-esophageal fistula with precision given the
limited number of patients in the trials and the continued
evolution of the technique. However, the rate of serious
complications is expected to be low, likely in the
1-3% range.
Based on these findings, TEC criteria were met for
two indications: 1) patients with symptomatic paroxysmal
or persistent atrial fibrillation, who have failed
treatment with antiarrhythmic drugs; and 2) patients
with symptomatic atrial fibrillation and congestive
heart failure, who have failed treatment with standard
medications for rate control and who would otherwise
be considered for AV nodal ablation and pacemaker insertion.
For the first indication, the conclusion followed from
the premise that reducing episodes of recurrent atrial
fibrillation for this population will reduce or eliminate
the symptoms associated with episodes of atrial fibrillation.
For the latter indication, the single multicenter randomized,
controlled trial available was judged sufficient to
conclude that catheter ablation improved outcomes compared
to the alternative, AV nodal ablation and pacemaker
insertion. While this trial was relatively small, it
was judged to be otherwise of high quality and reported
improvements of a relatively large magnitude across
a range of clinically important outcome measures, including
QOL, exercise tolerance, left ventricular ejection
fraction, and maintenance of sinus rhythm.
Since the 2008 TEC Assessment, Forleo and colleagues
enrolled 70 patients with type II diabetes mellitus
and paroxysmal or persistent atrial fibrillation for
at least six months duration resistant to one or more
trials of antiarrhythmic drugs. [15] Patients were
randomized to radiofrequency pulmonary vein isolation
(PVI) or a new antiarrhythmic drug regimen and followed
up for one year. The primary outcome was recurrence
of atrial fibrillation, and secondary outcomes were
the SF-36 health status questionnaire, thromboembolic
events, bleeding, and hospitalizations. Holter monitoring
was performed at 3-month intervals to assess recurrence
of atrial fibrillation. At one year, 20% of patients
in the ablation group had atrial fibrillation recurrence,
compared with 57% in the antiarrhythmic drug group
(p<0.001). Hospitalizations were more frequent in
the drug group (34.3% vs. 8.6%, p<0.01). The ablation
group had greater mean improvements on 5 of 8 subscales
on the SF-36 questionnaire (p<0.05). The mean improvements
on these subscales (0–100 scale) were 8.9 points
for general health, 8.4 for physical functioning, 7.7
for social functioning, 6.8 for role emotional, and
5.5 for bodily pain. An improvement of 5–10 points
is considered a clinically significant change for the
SF-36 measures. This study corroborates previous evidence
demonstrating the superiority of catheter ablation
in reducing atrial fibrillation recurrence in patients
who have failed antiarrhythmic drugs. It also adds
to accumulating evidence that catheter ablation is
associated with improvements in quality of life compared
to continued antiarrhythmic drug treatment.
Numerous other randomized, controlled trials compared
variations of the technique for performing radiofrequency
ablation such as the location and extent of ablations
performed, the use of navigation aids and novel catheters,
and the use of computed tomographic image integration. [16-21] These
randomized, controlled trials do not provide clear
evidence of the superiority of one type of technique
over others.
Two systematic reviews published in 2008 summarized
and synthesized the randomized, controlled trial evidence
on catheter ablation versus alternate therapy. These
reviews included four of the six trials reviewed for
the TEC Assessment. Noheria and colleagues [22] included
three of these four randomized, controlled trials [9-11] as
well as an additional small randomized, controlled
trial of 30 patients not included in the TEC Assessment.
[23] Gjiesdal and colleagues [24] included
five randomized, controlled trials in their analysis,
including the four trials in the Noheria systematic
review summarized below, and one additional trial (included
in TEC Assessment) that compared catheter ablation
plus antiarrhythmic drugs with antiarrhythmic drugs
alone. [8] Both of these systematic reviews
concluded that catheter ablation was more effective
than pharmacologic treatment in maintaining normal
sinus rhythm.
In combined analysis, Noheria and colleagues reported
atrial-fibrillation-free survival at one year to be
75.7% in the catheter-ablation group compared to 18.8%
in the comparison group. [22] The relative
risk for maintaining sinus rhythm was 3.73 (95% CI:
2.47-5.63) for the catheter-ablation group compared
to alternative treatment. Gjiesdal and colleagues [24] concluded that the available evidence was of moderate
quality, and consistent in reporting the atrial-fibrillation-free
survival was superior for the catheter ablation group;
however, due to unexplained heterogeneity, these authors
did not perform a combined analysis.
Piccini and colleagues conducted a meta-analysis of
randomized, controlled trials to compare the efficacy
and safety of pulmonary vein isolation (PVI) with medical
therapy at 12-months follow-up. [25] Six trials with
a combined total of 693 patients met inclusion criteria.
The authors reported freedom from atrial fibrillation
of 77% of patient receiving PVI and 29% of patients
on medical treatment. PVI was also associated with
decreased hospitalization for cardiovascular causes
(14% vs. 93%). Repeat PVI was required in 17% of PVI
patients.
Society Guidelines and Consensus Statements
In 2006, the American College of Cardiology published
an update to their practice guidelines for the treatment
of atrial fibrillation. [3] These guidelines
reflect the results of the rate versus rhythm controlled
randomized studies. Explicit recommendations were classed
as I, IIa, IIb, or III. Class IIa is defined as: “the
weight of evidence or opinion is in favor of the procedure
or treatment.” The recommendations were further
classified according to the type of data available.
Class C data were defined as “expert consensus.” The
guidelines described the use of ablation of the pulmonary
vein and noted that the “…technique of
ablation has continued to evolve from early attempts
to target individual ectopic foci within the PV to
circumferential electrical isolation of the entire
PV musculature.” The following two specific recommendations
regarding the use of catheter ablation were judged
class IIa:
- It is reasonable to use ablation of the AV node
or accessory pathway to control heart rate when pharmacological
therapy is insufficient or associated with side effects (Level
of Evidence: B)
- Catheter ablation is a reasonable alternative to
pharmacological therapy to prevent recurrent AF in
symptomatic patients with little or no left atrial
enlargement. (Level of Evidence: )
The guidelines also encouraged further research in
this area given uncertainties in patient populations,
technique, and outcome assessment. The authors stated
that “despite these advances, the long-term efficacy
of catheter ablation to prevent recurrent AF requires
further study.”
The American College of Physicians and American Academy
of Family Physicians issued clinical practice guidelines
in 2003 for patients with new onset AF [26].
These guidelines stated that the majority of patients
with new onset AF should be treated with a pharmacologic
rate control strategy and long-term anticoagulation.
Similar to the ACC/AHA guidelines, this document did
not include specific recommendations for catheter-based
ablation techniques in their treatment algorithms.
Repeated procedures
Repeated procedures for recurrent atrial fibrillation
or atrial flutter were commonly performed in most of
the clinical trials included in this policy statement.
Of the seven randomized, controlled trials reviewed,
only two [9,15] did not include repeated
procedures. In the other five studies, one or more
repeated procedures were allowed, and success rates
reported generally incorporated the results of up to
three procedures. In three studies that reported these
data, repeated procedures were performed in 9% [11],
20% [13], and 32% [8] of patients
randomized to ablation. Stabile and colleagues did
not report specifics on how many patients actually
underwent repeated procedures, but limited data in
the publication indicated that up to 30% of treated
patients were eligible for repeated procedures. [10] In
the Jais et al study, patients underwent a mean of
1.8 procedures per patient and a median of two procedures
per patient, indicating that approximately 50% of patients
in the ablation group underwent at least one repeated
procedure. [12]
Because of this high rate of repeated procedures,
the results reported in these studies do not reflect
the success of a single procedure. Rather, they more
accurately estimate the success of an ablation strategy
that includes repeated procedures for recurrences that
occur within the first year of treatment. Nonrandomized
evidence suggests that early reablation increases the
success of the procedure, when defined as maintenance
of sinus rhythm at 1 year. [27] There is variability
in the protocol for when repeated procedures should
be performed. There is also uncertainty concerning
other details on repeated procedure, such as how soon
after the initial procedure it should be done, the
threshold of atrial fibrillation recurrence that should
prompt a repeat, and whether medications should be
tried prior to a repeated procedure.
Summary
- The evidence is sufficient to conclude that catheter
ablation may be appropriate or patients with symptomatic
atrial fibrillation who have failed antiarrhythmic
medications. For these patients, maintenance of sinus
rhythm will lead to an improvement in symptoms and
therefore will improve outcomes.
- For the larger population of patients with atrial
fibrillation whose symptoms are adequately controlled
by rate control, the evidence is not sufficient to
conclude that outcomes are improved. Therefore, there
is insufficient evidence to support the use of catheter
ablation as first-line treatment.
- For the small subset of patients with atrial fibrillation
and congestive heart failure, in whom standard medications
for atrial fibrillation have failed to adequately
control ventricular rate, the evidence is sufficient
to conclude that catheter ablation improves outcomes
compared to the alternative, AV nodal ablation and
pacemaker insertion.
- Up to two repeat procedures may be needed following
initial ablation in order to achieve complete control
of atrial fibrillation or flutter.
- The randomized, controlled trials comparing variations
of catheter ablation underscore the continued evolution
of the procedure, and the uncertainty that exists
regarding the optimal approach for catheter ablation
to treat atrial fibrillation.
References
- BlueCross BlueShield Association Medical Policy
Reference Manual "Radiofrequency Catheter Ablation
of the Pulmonary Veins as Treatment for Atrial Fibrillation " Policy
No. 2.02.19
- Shemin, RJ, Cox, JL, Gillinov, AM, Blackstone, EH,
Bridges, CR. Guidelines for reporting data and outcomes
for the surgical treatment of atrial fibrillation.
Ann Thorac Surg. 2007 Mar;83(3):1225-30. PMID:
17307507
- Fuster, V, Ryden, LE, Cannom, DS, et al. ACC/AHA/ESC
2006 guidelines for the management of patients with
atrial fibrillation--executive summary: a report
of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines and
the European Society of Cardiology Committee for
Practice Guidelines (Writing Committee to Revise
the 2001 Guidelines for the Management of Patients
With Atrial Fibrillation). J Am Coll Cardiol. 2006
Aug 15;48(4):854-906. PMID: 16904574
- 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 Dec 5;347(23):1825-33. PMID:
12466506
- 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 Dec 5;347(23):1834-40. PMID:
12466507
- Falk, RH. Management of atrial fibrillation--radical
reform or modest modification? N Engl J Med. 2002
Dec 5;347(23):1883-4. PMID: 12466514
- TEC Assessment "Radiofrequency Catheter Ablation
of the Pulmonary Veins for Treatment of Atrial Fibrillation." BlueCross
BlueShield Association Technology Evaluation Center,
Vol. 23 Tab. 11.
- Oral, H, Pappone, C, Chugh, A, et al. Circumferential
pulmonary-vein ablation for chronic atrial fibrillation.
N Engl J Med. 2006 Mar 2;354(9):934-41. PMID:
16510747
- Wazni, OM, Marrouche, NF, Martin, DO, et al. Radiofrequency
ablation vs antiarrhythmic drugs as first-line treatment
of symptomatic atrial fibrillation: a randomized
trial. JAMA. 2005 Jun 1;293(21):2634-40. PMID:
15928285
- Stabile, G, Bertaglia, E, Senatore, G, et al.
Catheter ablation treatment in patients with drug-refractory
atrial fibrillation: a prospective, multi-centre,
randomized, controlled study (Catheter Ablation For
The Cure Of Atrial Fibrillation Study). Eur Heart
J. 2006 Jan;27(2):216-21. PMID: 16214831
- Pappone, C, Augello, G, Sala, S, et al. A randomized
trial of circumferential pulmonary vein ablation
versus antiarrhythmic drug therapy in paroxysmal
atrial fibrillation: the APAF Study. J Am Coll Cardiol.
2006 Dec 5;48(11):2340-7. PMID: 17161267
- Jais, P, Cauchemez, B, Macle, L, et al. Catheter
ablation versus antiarrhythmic drugs for atrial fibrillation:
the A4 study. Circulation. 2008 Dec 9;118(24):2498-505. PMID:
19029470
- Khan, MN, Jais, P, Cummings, J, et al. Pulmonary-vein
isolation for atrial fibrillation in patients with
heart failure. N Engl J Med. 2008 Oct 23;359(17):1778-85. PMID:
18946063
- The clinicaltrial.gov website. [cited
3/15/10]; Available from: http://www.clinicaltrials.gov/ct2/search
- Forleo, GB, Mantica, M, De Luca, L, et al. Catheter
ablation of atrial fibrillation in patients with
diabetes mellitus type 2: results from a randomized
study comparing pulmonary vein isolation versus antiarrhythmic
drug therapy. J Cardiovasc Electrophysiol. 2009 Jan;20(1):22-8. PMID:
18775050
- Rajappan, K, Baker, V, Richmond, L, et al. A randomized
trial to compare atrial fibrillation ablation using
a steerable vs. a non-steerable sheath. Europace.
2009 May;11(5):571-5. PMID: 19351628
- Della Bella, P, Fassini, G, Cireddu, M, et al.
Image integration-guided catheter ablation of atrial
fibrillation: a prospective randomized study. J Cardiovasc
Electrophysiol. 2009 Mar;20(3):258-65. PMID:
19261038
- Oral, H, Chugh, A, Yoshida, K, et al. A
randomized assessment of the incremental role of
ablation of complex fractionated atrial electrograms
after antral pulmonary vein isolation for long-lasting
persistent atrial fibrillation. J Am Coll Cardiol.
2009 Mar 3;53(9):782-9. PMID: 19245970
- Deisenhofer, I, Estner, H, Reents, T, et al. Does
electrogram guided substrate ablation add to the
success of pulmonary vein isolation in patients with
paroxysmal atrial fibrillation? A prospective, randomized
study. J Cardiovasc Electrophysiol. 2009 May;20(5):514-21. PMID:
19207759
- Perez-Castellano, N, Villacastin, J, Salinas,
J, et al. Cooled ablation reduces pulmonary vein
isolation time: results of a prospective randomised
trial. Heart. 2009 Mar;95(3):203-9. PMID:
18070948
- Khaykin, Y, Skanes, A, Champagne, J, et
al. A randomized controlled trial of the efficacy
and safety of electroanatomic circumferential pulmonary
vein ablation supplemented by ablation of complex
fractionated atrial electrograms versus potential-guided
pulmonary vein antrum isolation guided by intracardiac
ultrasound. Circ Arrhythm Electrophysiol. 2009 Oct;2(5):481-7. PMID:
19843915
- Noheria, A, Kumar, A, Wylie, JV, Jr., Josephson,
ME. Catheter ablation vs antiarrhythmic drug therapy
for atrial fibrillation: a systematic review. Arch
Intern Med. 2008 Mar 24;168(6):581-6. PMID:
18362249
- Krittayaphong, R, Raungrattanaamporn, O, Bhuripanyo,
K, et al. A randomized clinical trial of the efficacy
of radiofrequency catheter ablation and amiodarone
in the treatment of symptomatic atrial fibrillation.
J Med Assoc Thai. 2003 May;86 Suppl 1:S8-16. PMID:
12866763
- Gjesdal, K, Vist, GE, Bugge, E, et al. Curative
ablation for atrial fibrillation: a systematic review.
Scand Cardiovasc J. 2008 Feb;42(1):3-8. PMID:
18273730
- Piccini, JP, Lopes, RD, Kong, MH, Hasselblad,
V, Jackson, K, Al-Khatib, SM. Pulmonary vein isolation
for the maintenance of sinus rhythm in patients with
atrial fibrillation: a meta-analysis of randomized,
controlled trials. Circ Arrhythm Electrophysiol.
2009 Dec;2(6):626-33. PMID: 20009077
- Snow, V, Weiss, KB, LeFevre, M, et al. Management
of newly detected atrial fibrillation: a clinical
practice guideline from the American Academy of Family
Physicians and the American College of Physicians.
Ann Intern Med. 2003 Dec 16;139(12):1009-17. PMID:
14678921
- Lellouche, N, Jais, P, Nault, I, et al. Early
recurrences after atrial fibrillation ablation: prognostic
value and effect of early reablation. J Cardiovasc
Electrophysiol. 2008 Jun;19(6):599-605. PMID: 18462321
Cross References
None
| Codes |
Number |
Description |
| There is no specific CPT code for
ablation that targets arrhythmogenic foci in the
pulmonary vein. CPT code 93799, unlisted cardiovascular
service or procedure, may be used to report this
service. CPT code 93651 is for ablation that targets
atrial arrhythmogenic foci, not foci within the
pulmonary vein and, therefore, should not be
used to report pulmonary vein isolation procedures. |
Surgery Section Table of Contents 

|