Complications of Atrial Fibrillation Ablation

When Prevention Is Better Than Cure

Antonio Sorgente; Gian-Battista Chierchia; Carlo de Asmundis; Andrea Sarkozy; Lucio Capulzini; Pedro Brugada


Europace. 2011;13(11):1526-1532. 

In This Article

Abstract and Introduction


As atrial fibrillation ablation is becoming increasingly popular in many cardiac electrophysiological laboratories around the world, preventing, avoiding, or treating procedure-related complications is of utmost importance. In our review of the literature regarding this issue, we addressed in detail all the potential collateral and undesired effects associated to this intervention.


Pulmonary vein isolation (PVI) is a well-known option for the treatment of both paroxysmal and persistent atrial fibrillation (AF).[1] The lack of new effective antiarrhythmic drugs and the side effects linked to the acute and chronic use of the old ones have favoured the development and the implementation of AF catheter ablation, which, nowadays, can be obtained with different strategies and/or technologies.[1]

Since its first introduction in the cardiological context in the late nineties,[2] the technique, which allows electrical isolation of pulmonary vein muscle sleeves from the left atrium, has improved by leaps and bounds. Although this good news, complications are still present and cannot be ignored. Plenty of literature has already been produced on the description and the characterization of the complications of AF ablation, as well as on their management.[1] Taking this in mind, the aim of this review is to list them briefly but, above all, to describe possible strategies to reduce their incidence. The present manuscript does not want to substitute the more authoritative and reliable publications on the topic,[1,3] but, more simply, to increase the awareness on a topic that could be easily underestimated or ignored by the younger and less-experienced cardiac electrophysiologists.

A worldwide survey on the methods, efficacy, and safety of AF catheter ablation recently published by Cappato et al.[4] revealed that the indications for AF catheter ablation have been progressively widened. Today, AF catheter ablation is offered to a wider number of patients compared with the first years of its clinical application. This could explain why the overall success of the procedure has not increased significantly and why complication rates including the incidence of iatrogenic flutter has not decreased despite the great improvement in both the experience of the operators and the accuracy of the principal mapping systems used during AF catheter ablation.

Complications of AF ablation express themselves through very different clinical scenarios which vary from local issues (related to the percutaneous access which precedes catheter ablation) to life-threatening conditions. According to the most recent international guidelines on AF ablation,[1] 'a major complication is defined as a complication that results in permanent injury or death, requires intervention for treatment, or prolongs or requires hospitalization'.

An outstanding contribution to the description and quantification of complications of AF ablation has been given by three different groups of authors.[5–7] Complication rates varied from a minimum of 0.8% to a maximum of 5%. No periprocedural deaths were reported in any of these studies. Interestingly, treatment with clopidogrel, female gender and AF ablations performed in July or August were independent predictors of vascular complications, whereas advanced age and female gender predicted the occurrence of major adverse events. The only predictor of cardiac tamponade was prior radiofrequency AF catheter ablation.

In the most recent worldwide survey by Cappato et al., complications have been observed in 4.5% of patients undergone AF ablation. Death accounted for 0.15% of total complications, whereas atrio-oesophageal fistula happened in 0.04% of procedures. Cardiac tamponade complicated 1.31 % of total procedures. Stroke occurred in 0.23 %, transient ischaemic attack in 0.71% and PV stenosis requiring surgical or percutaneous dilation in 0.29%. Among minor complications, total femoral pseudoaneurysms accounted for 0.93% whereas total artero-venous fistulae have been observed in 0.54% of the total procedures. Iatrogenic atrial flutters were almost doubled compared with the first survey performed by the same group of investigators between 1995 and 2002.

Each complication will be treated in turn.