Concise Guidelines of the European Cardiac Arrhythmias Society (ECAS) on “Catheter Ablation of Atrial Fibrillation”

Guidelines have been introduced to provide “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” [1]. Since their introduction, they have been a valuable tool for a large population of stakeholders, including physicians, patients, hospitals, educational bodies, manufacturers, health providers and insurers in medicine. While guidelines are meant to help professionals in taking routine clinical decisions, there are very few studies possessing the quality required to generate solid recommendations. Despite limited high-quality evidence, guidelines typically consist of full-bodied texts and tables reporting extensive lists of recommendation [2-4]. To compensate for lack of evidence-based documentation, studies of incomplete quality and condensed judgment among authors are used to generate recommendations of intermediate class enriched with sub-categorization based on multiple arbitrarily generated “levels of evidence”. Frequent updating produced by different scientific bodies adds to the model complexity. In addition, guidelines are increasingly perceived as creating unjustified legal liability for practitioners despite the limited evidence on which they are based. To address this, processes have been proposed to impose rigor and transparency with which guideline documents are developed [5, 6] to assess the quality of guidelines, provide a methodological strategy for their development, and clarify what information and how this information should be reported in guideline documents [7, 8]. As a result, guidelines should contract in volume and re-direct focus on recommendations based on clinical indications supported by more solid evidence. Criteria adopted to substantiate the need for high-quality in our guidelines are described in paragraphs “Criteria for Class I, Class II and Class III recommendations” of Chapter 5. Catheter ablation of AF represents a situation in which high-quality studies are rather limited. Yet, guidelines and consensus documents have resulted in the production of copious documents [2-4, 9]. With the intent of producing a guideline that serves its intended purpose and reconciling with the art of medicine, the European Cardiac Arrhythmia Society (ECAS) proposes a concise and coordinate document to assist practitioner and patient decisions in this field. ECAS is an independent society founded in 2004 in Paris with the mission to promote the discipline of better care in diagnosing and treating cardiac arrhythmias. The criteria used in this document to define recommendation classes are summarized in the paragraph “criteria for recommendations” below. This Guideline document was registered on PREPARE (Practice guideline Registration for transparency; registration number: PREPARE-2024CN005) in February 2024. Multiple searches for randomized controlled trials to inform this document were performed. These were done as part of purpose-built systematic reviews which have meanwhile been published as separate manuscripts and present information on the detailed search strategy, PICO approach and questions addressed by the Guideline and each of the Reviews. Randomized controlled trials meeting the inclusion criteria for our systematic reviews were included. Additionally, randomized controlled trials not addressing other aspects of the guideline not covered by the systematic reviews, but that were identified through the search process were also considered eligible [10]. An update of the guidelines is planned, with the definition of guideline questions and search starting, up to 5 years following the publication date of the present document. An earlier update may occur, if justified, driven by novel technology or publication of impactful evidence on a field not covered by this document. In such circumstances, the decision may be for updating only that section of the guideline, rather than the whole document. “The logic of science is hypothetical. To be powerful, science required to turn its back to the incontrovertible thruth. No matter how strong their degree of confirmation, scientific hypotheses can be ‘falsifiable’ at any time” [11]. Definition of truth in science has been subjected to considerable modifications over time [12]. In the 2nd century A.C., Ptolemy proposed a cosmologic model according to which the earth would stand motionless at the center of universe. It took 13 centuries before Copernicus proposed a new, revolutionary model supporting the concept that the earth would rotate around the sun and one more century before Copernicus theory became widely accepted [13]. In the present era, technological development accelerates progress in science and communication. As a result, even when created using high-quality science, guidelines become out of date quickly. Therefore, it is inevitable that current methods for producing guidelines will be reviewed and changed in the future. The universal adoption of evidence-based medicine has recast medical knowledge in such a way that experimental studies designed to validate single isolated interventions take on the highest status and, by so doing, undermine clinical judgment and lock in place a reductive model of health and disease [10, 13]. In the present document, evidence-based medicine will be used solely as a reference point for management of AF. This is consistent with the methods used by other societies in guidelines preparation and is taken under the assumption that new paradigms may surface in the future that offer different base theories, methods of investigation and validation that may subvert the current guideline's structure. First introduced in old French speaking as a derivation of the Medieval Latin recommendationem (nominative recommendatio), the word recommendation is intended as the “act of representing (something) in a favorable manner, the act of recommending (someone or something) as worthy” [14]. While consistent with this definition in the early days, guideline recommendations have lost their original meaning as they have escalated to a level close to imperative statements. 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