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


Death is an infrequent complication of AF catheter ablation. As showed by Cappato et al.,[8] peri-procedural death incidence observed in catheter ablation of AF does not differ from the incidence of peri-procedural death in catheter ablation of supraventricular tachycardias.[9,10] Nevertheless, it is also true that a scientific estimation of the causes leading to death during or after an AF catheter ablation is often prejudiced by the very small number of events and/or by the reticence of the operators to go into details when such an event occurs.

Many are the factors which can turn complications occurring during or after AF catheter ablation into death: the need of a transseptal puncture to reach the left atrium and the PV ostia, the handling and manipulation of catheters in the left atrium and the association of radiofrequency-dependent lesions in the left atrium with very high levels of anticoagulation. On this subject, very recently, two independent groups of investigators have demonstrated in a swine cardiac model that the probability of cardiac perforation is directly proportional to the contact force exerted by ablation catheters on cardiac walls and that radiofrequency energy reduces by some extent the minimal contact force needed to perforate the heart.[11,12] New ablation catheters able to detect beat by beat contact force will be very soon available and will help electrophysiologists both in understanding the real impact of the handling of catheters on cardiac tissues and hopefully in avoiding any type of cardiac rupture.

Cardiac tamponade (both acute and/or late) has demonstrated to be the most common fatal complication leading to cardiac arrest during or after AF catheter ablation, followed by development of atrio-oesophageal fistulas. Ischaemic brain or cardiac insults are the third most frequent causes of death followed by extrapericardial bleedings related to subclavian or PV perforation and by post-operative massive pneumonia refractory to antibiotics. Less represented and also less specific are deaths related to conditions such as torsade de pointes, sudden respiratory failure, or acute respiratory distress syndromes in the post-operative context. The strategy adopted to perform PVI (CARTO-guided vs. Lasso-guided or irrigated tip ablation vs. 4 mm tip ablation) seems not to affect the incidence of death during or after AF catheter ablation.[13] Even if it seems that also centre experience does not influence the rate of death related to AF catheter ablation, in our opinion it is far safer to have an AF ablation procedure performed at a referral centre than in a community hospital with little experience.