Advertisement

How to recognize, manage, and prevent complications during atrial fibrillation ablation

Published:December 01, 2006DOI:https://doi.org/10.1016/j.hrthm.2006.10.034
      Seminal observations by Haissaguerre et al
      • Haissaguerre M.
      • Jais P.
      • Shah D.C.
      • Takahashi A.
      • Hocini M.
      • Quiniou G.
      • Garrigue S.
      • Le Mouroux A.
      • Le Metayer P.
      • Clementy J.
      Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins.
      demonstrating initiation of atrial fibrillation (AF) by pulmonary vein (PV) depolarizations led to the development of percutaneous catheter-based endocardial AF ablation procedure. Since its original description, the AF ablation procedure has evolved considerably. Currently, the most accepted ablation strategy involves creating circumferential radiofrequency (RF) ablation lesions around PV ostia (either individually or encircling wide areas around the left-sided and right-sided veins) with or without additional atrial lesions.
      • Oral H.
      • Scharf C.
      • Chugh A.
      • Hall B.
      • Cheung P.
      • Good E.
      • Veerareddy S.
      • Pelosi F.
      • Morady F.
      Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation.
      Using this approach, investigators are reporting long-term arrhythmia control/cure rates ≥70%.
      • Oral H.
      • Scharf C.
      • Chugh A.
      • Hall B.
      • Cheung P.
      • Good E.
      • Veerareddy S.
      • Pelosi F.
      • Morady F.
      Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation.
      • Callans D.J.
      • Gerstenfeld E.P.
      • Dixit S.
      • Zado E.
      • Vanderhoff M.
      • Ren J.
      • Marchlinski F.E.
      Efficacy of recurrent pulmonary vein isolation procedures in patients with recurrent atrial fibrillation.
      However, creating these lesions uses multiple intracardiac catheters and requires a significant degree of “invasiveness” while maintaining high levels of anticoagulation, all of which make possible the occurrence of various potentially life-threatening complications. In a summary of a worldwide survey of >8,000 patients who underwent catheter ablation for AF, Cappato et al
      • Cappato R.
      • Calkins H.
      • Chen S.
      • Davies W.
      • Iesaka Y.
      • Kallman J.
      • Kim Y.
      • Klien G.
      • Packer D.
      • Skanes A.
      Worldwide survey on the methods, efficacy and safety of catheter ablation for human atrial fibrillation.
      report an overall 4% occurrence of complications such as pericardial effusion–cardiac tamponade, cerebrovascular events, and PV stenosis. This compilation provides a reasonable estimate of overall risk associated with the procedure in the general electrophysiology community. The purpose of this article is to provide the readers with a concise review on how to diagnose and manage the common complications that may be encountered in patients undergoing the AF ablation procedure (Figure 1). In general, the majority of these complications typically are encountered early (during or within 48 hours of completing the procedure), although some (PV stenosis, esophageal fistula) may occur beyond the index hospitalization. Similarly, whereas the majority of these complications manifest dramatic symptoms and distinct physical signs, a few of them can have an insidious onset and/or remain completely asymptomatic.
      Figure thumbnail gr1
      Figure 1Overview of the different complications that may be encountered at various steps during atrial fibrillation ablation procedure.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Haissaguerre M.
        • Jais P.
        • Shah D.C.
        • Takahashi A.
        • Hocini M.
        • Quiniou G.
        • Garrigue S.
        • Le Mouroux A.
        • Le Metayer P.
        • Clementy J.
        Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins.
        N Engl J Med. 1998; 339: 659-666
        • Oral H.
        • Scharf C.
        • Chugh A.
        • Hall B.
        • Cheung P.
        • Good E.
        • Veerareddy S.
        • Pelosi F.
        • Morady F.
        Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation.
        Circulation. 2003; 108: 2355-2360
        • Callans D.J.
        • Gerstenfeld E.P.
        • Dixit S.
        • Zado E.
        • Vanderhoff M.
        • Ren J.
        • Marchlinski F.E.
        Efficacy of recurrent pulmonary vein isolation procedures in patients with recurrent atrial fibrillation.
        J Cardiovasc Electrophysiol. 2004; 15: 1050-1055
        • Cappato R.
        • Calkins H.
        • Chen S.
        • Davies W.
        • Iesaka Y.
        • Kallman J.
        • Kim Y.
        • Klien G.
        • Packer D.
        • Skanes A.
        Worldwide survey on the methods, efficacy and safety of catheter ablation for human atrial fibrillation.
        Circulation. 2005; 111: 1100-1105
        • Kok L.C.
        • Mangrum J.M.
        • Haines D.E.
        • Mounsey J.P.
        Cerebrovascular complications associated with pulmonary vein ablation.
        J Cardiovasc Electrophysiol. 2002; 13: 764-767
        • Ren J.
        • Marchlinski F.E.
        • Callans D.J.
        Left atrial thrombus associated with ablation for atrial fibrillation: identification with intracardiac echocardiography.
        J Am Coll Cardiol. 2004; 43: 1861-1867
        • Lickfett L.M.
        • Sommer T.
        • Hackenbroch M.
        • Selbach S.
        • Schwab J.O.
        • Yang A.
        • Balta O.
        • Schrickel J.W.
        • Andrie R.
        • Mittmann-Braun E.L.
        • Nickenig G.
        • Lewalter T.
        Incidence of asymptomatic cerebral embolism associated with cooled-tip pulmonary vein ablation: a study using segmental ostial ablation and cerebral diffusion weighted magnetic resonance imaging (abstr).
        Heart Rhythm. 2006; 3 (AB27–1.)
        • Ren J.
        • Marchlinski F.E.
        • Callans D.J.
        • Gerstenfeld E.P.
        • Dixit S.
        • Lin D.
        • Nayak H.M.
        • Hsia H.H.
        Increased intensity of anticoagulation may reduce risk of thrombus during atrial fibrillation ablation procedures in patients with spontaneous echo contrast.
        J Cardiovasc Electrophysiol. 2005; 16: 474-477
        • Querishi A.M.
        • Preito L.R.
        • Latson L.A.
        • Lane G.K.
        • Mesia C.I.
        • Radvansky P.
        • White R.D.
        • Marrouche N.F.
        • Saad E.B.
        • Bash D.L.
        • Natale A.
        • Rhodes J.F.
        Transcatheter angioplasty for acquired pulmonary vein stenosis after radiofrequency ablation.
        Circulation. 2003; 108 (1366–1342.)
        • Ren J.
        • Marchlinski F.E.
        • Callans D.C.
        • Zado E.S.
        Intracardiac Doppler echocardiographic quantification of pulmonary flow velocity: an effective technique for monitoring pulmonary vein narrowing during focal atrial fibrillation ablation.
        J Cardiovasc Electrophysiol. 2002; 13: 1076-1081
        • Saad E.B.
        • Rossilli A.
        • Saad C.P.
        • Martin D.O.
        • Bhargava M.
        • Erciyes D.
        • Bash D.
        • Williams-Andrew M.
        • Beheiry S.
        • Marrouche N.F.
        • Adams J.
        • Pisano E.
        • Raffaele F.
        • Potenza D.
        • Raviele A.
        • Bonso A.
        • Themistoclakis S.
        • Brachmann J.
        • Saliba W.I.
        • Schwiekert R.A.
        • Natale A.
        Pulmonary vein stenosis after radiofrequency ablation of atrial fibrillation: functional characterization, evolution and influence of ablation strategy.
        Circulation. 2003; 108: 3102-3107
        • Dixit S.
        • Ren J.
        • Callans D.J.
        • Gerstenfeld E.P.
        • Zado E.
        • Vanderhoff M.
        • Marchlinski F.E.
        Favorable effect of pulmonic vein isolation by partial circumferential ablation on ostial flow velocity.
        Heart Rhythm. 2004; 1: 262-267
        • Doll N.
        • Borger M.
        • Fabricius A.
        • et al.
        Esophageal perforation during left atrial ablation: is the risk too high?.
        J Thorac Cardiovasc Surg. 2003; 125: 836-842
        • Pappone C.
        • Oral H.
        • Santinelli V.
        • Vicedomini G.
        • Lang C.C.
        • Manguso F.
        • Torracca L.
        • Benussi S.
        • Alfieri O.
        • Hong R.
        • Lau W.
        • Hirata K.
        • Shikuma N.
        • Hall B.
        • Morady F.
        Atrio-esophageal fistula as a complication of percutaneous catheter ablation of atrial fibrillation.
        Circulation. 2004; 109: 2724-2726
        • Ho S.Y.
        • Cabrera J.A.
        • Farre J.
        • Anderson R.H.
        • Sanchez-Quintana D.
        Architecture of pulmonary veins: relevance to radiofrequency ablation.
        Heart. 2001; 86: 265-270
        • Cummings J.E.
        • Scweikert R.A.
        • Saliba W.I.
        • Burkhardt D.
        • Brachmann J.
        • Gunther J.
        • Schibgilla V.
        • Verma A.
        • Dery M.
        • Drago J.L.
        • Kilicaslan F.
        • Natale A.
        Assessment of temperature, proximity and course of esophagus during radiofrequency ablation within the left atrium.
        Circulation. 2005; 112: 459-464
        • Karch M.R.
        • Zrenner B.
        • Deisenhoffer I.
        • Schreieck J.
        • Ndrepepa G.
        • Dong J.
        • Lamprecht K.
        • Barthel P.
        • Luciani E.
        • Schomig A.
        • Schmitt C.
        Freedom for atrial tachyarrhythmias after catheter ablation of atrial fibrillation: a randomized comparison between 2 ablation strategies.
        Circulation. 2005; 111: 2875-2880
        • Mesas C.E.
        • Pappone C.
        • Lang C.C.E.
        • Gugliotta F.
        • Tomita T.
        • Vicedomini G.
        • Sala S.
        • Paglino G.
        • Gulletta S.
        • Ferro A.
        • Santinelli V.
        Left atrial tachycardia after circumferential pulmonary vein ablation for atrial fibrillation.
        J Am Coll Cardiol. 2004; 44: 1071-1079
        • Gerstenfeld E.P.
        • Callans D.J.
        • Dixit S.
        • Russo A.M.
        • Nayak H.
        • Lin D.
        • Pulliam W.
        • Siddique S.
        • Marchlinski F.E.
        Mechanisms of organized left atrial tachycardias occurring after pulmonary vein isolation.
        Circulation. 2004; 110: 1351-1357
        • Ouyang F.
        • Antz M.
        • Ernst S.
        • Hachiya H.
        • Mavrakis H.
        • Deger F.T.
        • Schaumann A.
        • Chun J.
        • Falk P.
        • Hennig D.
        • Liu X.
        • Bansch D.
        • Kuck K.
        Recurrent pulmonary vein conduction as the dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of pulmonary veins: lessons from double lasso technique.
        Circulation. 2005; 111: 127-135
        • Baim D.S.
        Percutaneous approach, including transseptal and apical puncture.
        in: Baim D.S. Grossman W. Cardiac Catheterization, Angiography and Intervention. Williams & Wilkins, Baltimore1996: 73-78
        • Bunch T.J.
        • Bruce G.K.
        • Mahapatra S.
        • Johnson S.B.
        • Miller D.V.
        • Sarabanda A.V.
        • Milton M.A.
        • Packer D.L.
        Mechanism of phrenic nerve injury during radiofrequency ablation at the pulmonary vein orifice.
        J Cardiovasc Electrophysiol. 2005; 16: 1318-1325
        • Wu R.C.
        • Brinker J.A.
        • Yuh D.D.
        • Berger R.D.
        • Calkins H.G.
        Circular mapping catheter entrapment in the mitral valve apparatus: a previously unrecognized complication of focal atrial fibrillation ablation.
        J Cardiovasc Electrophysiol. 2002; 13: 819-821
        • Mansour M.
        • Mela T.
        • Ruskin J.
        • Keane D.
        Successful release of entrapped circumferential mapping catheters in patients undergoing pulmonary vein isolation for atrial fibrillation.
        Heart Rhythm. 2004; 1: 558-561
        • Shah D.
        • Dumonceau J.M.
        • Burri H.
        • Sunthorn H.
        • Schroft A.
        • Gentil-Baron P.
        • Yokoyama Y.
        • Takahashi A.
        Acute pyloric spasm and gastric hypomotility: an extracardiac adverse effect of percutaneous radiofrequency ablation for atrial fibrillation.
        J Am Coll Cardiol. 2005; 46: 327-330
        • Ong M.G.
        • Tai C.
        • Lin Y.
        • Lee K.
        • Chang S.
        • Chen S.
        Sinus node injury as a complication of superior vena cava isolation.
        J Cardiovasc Electrophysiol. 2005; 16: 1243-1245
        • Takahashi Y.
        • Jais P.
        • Hocini M.
        • Sanders P.
        • Rotter M.
        • Rostock T.
        • Sacher F.
        • Jais C.
        • Clementy J.
        • Haissaguerre M.
        Acute occlusion of left circumflex coronary artery during mitral isthmus linear ablation.
        J Cardiovasc Electrophysiol. 2005; 16: 1104-1107
        • Jackman W.M.
        • Wang X.Z.
        • Friday K.J.
        • Roman C.A.
        • Moulton K.P.
        • Beckman K.J.
        • McClelland J.H.
        • Twidale N.
        • Hazlitt H.A.
        • Prior M.I.
        • et al.
        Catheter ablation of accessory atrioventricular pathways by radiofrequency current.
        N Engl J Med. 1991; 324: 1605-1611
        • Tsai C.F.
        • Chen S.A.
        • Tai C.T.
        • Chiou C.W.
        • Prakash V.S.
        • Yu W.C.
        • Hsieh M.H.
        • Ding Y.A.
        • Chang M.S.
        Bezold-Jarisch–like reflex during radiofrequency ablation of pulmonary vein tissue in patients with paroxysmal atrial fibrillation.
        J Cardiovasc Electrophysiol. 1999; 10: 27-35
        • Hsieh M.H.
        • Chiou C.W.
        • Wen Z.C.
        • Wu C.H.
        • Tai C.T.
        • Tsai C.F.
        • Ding Y.A.
        • Chang M.S.
        • Chen S.A.
        Alterations of heart rate variability after catheter ablation of focal atrial fibrillation originating from the pulmonary veins.
        Circulation. 1999; 100: 2237-2243
        • Adourian U.
        • Shampaine E.L.
        • Hirshman C.A.
        • Fuchs E.
        • Adkinson Jr, N.F.
        High-titer protamine-specific IgG antibody associated with anaphylaxis: report of a case and quantitative analysis of antibody in vasectomized men.
        Anesthesiology. 1993; 78: 368-372
        • Levy J.H.
        • Zaidan J.R.
        • Faraj B.
        Prospective evaluation of risk of protamine reactions in patients with NPH insulin-dependent diabetes.
        Anesth Analg. 1986; 65: 739-742