Catheter ablation of atrial fibrillation: anticipating and avoiding complications

ABSTRACT

Introduction

Atrial fibrillation (AF) ablation is being performed more frequently and more widely at more centers. This stems from several factors including 1) demographic forces leading to an increased prevalence of the arrhythmia; 2) greater availability of ambulatory monitoring making diagnosis more frequent; 3) relative inefficacy of medications; and 4) improved safety and efficacy of the procedure. Ablation has become much more streamlined and reproducible than a decade ago, but life-threatening complications may still arise.

Areas covered

This review will focus on awareness, avoidance, and early recognition and management of complications of AF ablation. This literature review is challenged by differing approaches to ablation of AF both within a center and between centers, the rapid improvement of technology making the outcomes associated with a therapeutic strategy begun a few years prior relatively obsolete, as well as the heterogeneity of the population being studied.

Expert opinion

Newer technologies are on the horizon which will allow us to ablate AF with increasing efficacy, efficiency, and hopefully safety. Such new technology and changing usage mandate vigilance to avoid complications.

KEYWORDS:

• Atrial fibrillation
• atrioesophageal fistula
• catheter ablation
• cardiac perforation
• cardiac tamponade
• complication prevention
• pulmonary vein stenosis
• vascular access complications

Article highlights

• Atrial fibrillation ablation is a commonly performed but complex procedure, and despite advances in safety and efficacy, procedural complications remain an important consideration. Awareness of these potential complications, preventative measures, and treatment strategies is crucial.

• Vascular access complications are common and a significant source of post-procedure morbidity. The frequency can be decreased with the consistent use of ultrasound when obtaining venous access.

• The use of intracardiac echocardiography is often invaluable in preventing cardiac tamponade, embolism, hemothorax, atrioesophageal fistula, and cardiac perforation leading to cardiac tamponade due to incorrect positioning during catheter manipulation or transseptal puncture.

• Severe pulmonary vein stenosis has become significantly less common with improvement of technology and technique. When it occurs, it requires close monitoring and occasionally angioplasty.

• Atrioesophageal fistula is a rare but life-threatening complication which typically presents after discharge. In addition to employing preventative measures, patients and emergency room providers should be educated on the possibility of this complication so as avoid a delay in surgical intervention.

• Initial data suggest that a high-power short-duration strategy will increase ablation efficacy without decreasing procedural safety, and pulsed field ablation is also expected to lead to improved efficacy and safety when compared to thermal ablation.

Declaration of interest

JP Daubert has received honoraria for being on advisory boards, steering committees, data safety monitoring boards, events committees, and/or performing lectures for Abbot, Acutus, Affera, Biosense Webster, Biotronik, Boston Scientific, CT Surgery Clinical Trials Network, Cordis, Medtronic, Microport, NHLBI, and Zoll. JP Daubert has also received research grants from Boston Scientific and Medtronic. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.