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Prof. Josep Brugada
Over the past decade, catheter ablation of atrial fibrillation has become a common procedure. The indications and technical aspects of the procedure are well defined. However the recommendations regarding long-term follow-up in order to detect early complications and recurrences, as well as its medical management, are scarce and vague. Learn about follow-up considerations, how to manage arrhythmic recurrences and complications during follow-up in this article.
Atrial fibrillation (AF) is the most frequent sustained cardiac arrhythmia, and in the last decade, catheter ablation has evolved from a nearly experimental and uncertain procedure, to a routine and well established one in many major hospitals around the world. Despite this fact, symptomatic AF refractory or intolerant to antiarrhythmic medication is the only accepted indication for AF ablation (Class IIb with a level of evidence C) , in daily clinical practice the indications have rapidly expanded. Thereby in those cases in which we expect a great benefit (as in highly symptomatic patients with congestive heart failure and/or depressed ejection fraction [2,3] or a high rate of success (as those with short episodes of paroxysmal AF, without structural heart disease, and normal left atrium size  AF ablation is recommended as first line therapy (table 1).
When we review published literature regarding outcomes of AF catheter ablation, we must be conscious of the potential factors that may impact outcome, including:
The Worldwide survey on methods, efficacy and safety of catheter ablation of AF , published in 2005, reported a success rate (defined as freedom from symptomatic AF in the absence of antiarrhythmic therapy) of 52%, with 6% major complications.
Analysis of the results reported in many prospective single centre studies [5,9,10-18], shows that the single procedure efficacy on paroxysmal AF ablation ranges from 38 to 78%, and it usually exceeds 70% when considering multiple procedures. However, reviewing the outcome on persistent AF ablation, success rate of the initial procedure does not reach 50%.
Catheter ablation is one of the most laborious electrophysiologic procedures, and although complications rate have decreased with the operators learning curve and technical improvements, major complications are still present in approximately 6% of patients. Even though most of the complications are detected during or immediately after the procedure, some of them will be detected during follow-up.
There are other complications, like cardiac tamponade, mitral valve trauma by entrapment of the circular catheter in the mitral vale apparatus, air embolism or acute coronary artery occlusion. All of them occur during the procedure, and require immediate treatment when diagnosed.
To conclude, complications are rare but potentially serious, and careful evaluation should be done in case of symptoms that might be referred by patients. In some cases, due to the rarity of the complication, the treatment is not well defined, and treatment should be done in highly specialized centres.
Table 1 : Indications for Catheter AF Ablation
Established indication (Class IIb, level of evidence C)
Figure 1 : General Schedule recommended for the follow-up of AF ablation procedure
(*): Anticoagulation can be interrupted if CHADS score < 2. The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.
1. HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-up: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (AHRA) and the European Cardiac Arrhtymia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and Approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Europace 2007;9:335-379. 2. Chen MS, Marrouche NF, Khaykin Y, Gillinov AM, Wazni O, Martin DO, Rossillo A, Verma A, Cummings J, Erciyes D, Saad E, Bhargava M, Bash D, Schweikert R, Burkhardt D, Williams-Andrews M, Perez-Lugones A, Abdul-Karim A, Saliba W, Natale A. Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function. J Am Coll Cardiol 2004;43:1004-1009. 3. Hsu LF, Jais P, Sanders P, Garrigue S, Hocini M, Sacher F, Takahashi Y, Rotter M, Pasquié JL, Scavée C, Bordachar P, Clémenty J, Haïssaguerre M. Catheter ablation of atrial fibrillation in congestive heart failure. N Engl J Med 2004;351:2373-2383. 4. Ouyang F, Bansch D, Ernst S, Schaumann A, Hachiya H, Chen M, Chun J, Falk P, Khanedani A, Antz M, Kuck KH. Complete isolation of left atrium surrounding the pulmonary veins. New insights from the double –lasso technique in paroxysmal atrial fibrillation. Circulation 2004;110:2090-2096. 5. Vasamreddy CR, Lickfett L, Javam VK, Nasir K, Bradley DJ, Eldadah Z, Dickfeld T, Berger R, Calkins H. Predictors of recurrence following catheter ablation of atrial fibrillation using an irrigated-tip ablation catheter. J Cardiovasc Electrophysiol 2004 Jun;15(6):692-7. 6. Berruezo A, Tamborero D, Mont L, Benito B, Tolosana JM, Sitges M, Vidal B, Arriagada G, Méndez F, Matiello M, Molina I, Brugada J. Pre-procedural predictors of atrial fibrillation recurrence after circumferential pulmonary vein ablation. Eur Heart J 2007 Apr 28(7):836-41. 7. Chilukuri K, Dalal D, Marine JE, Scherr D, Henrikson CA, Cheng A, Nazarian S, Spragg D, Berger R, Calkins H. Predictive value of obstructive sleep apnoea assessed by the Berlin Questionnaire for outcomes after the catheter ablation of atrial fibrillation. Europace 2009 Mar 18 [Epub ahead of print]. 8. Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. A worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation 2005;111:1100-1105. 9. Cheema A, Dong J, Dalal D, Vasamreddy CR, Marine JE, Henrikson CA, Spragg D, Cheng A, Nazarian S, Sinha S, Halperin H, Berger R, Calkins H. Long-term safety and efficacy of circumferential ablation with pulmonary vein isolation. J Cardiovasc Electrophysiol 2006;17:1080-1085. 10. Oral H, Chugh A, Good E, Sankaran S, Reich SS, Igic P, Elmouchi D, Tschopp D, Crawford T, Dey S, Wimmer A, Lemola K, Jongnarangsin K, Bogun F, Pelosi F Jr, Morady F. A tailored approach to catheter ablation of paroxysmal atrial fibrillation. Circulation 2006 Apr 18;113(15):1824-31. 11. Karch MR, Zrenner B, Deisenhofer I, Schereieck J, Ndrepepa G, Dong J, Lamprecht K, Barthel P, Luciani E, Schömig A, Schmitt C. Freedom from atrial tachyarrhytmias after catheter ablation of atrial fibrillation: a randomized comparison between 2 current ablation strategies. Circulation 2005;111:2875-2880. 12. Hocini M, Jais P, Sanders P, Takahashi Y, Rotter M, Rostock T, Hsu LF, Sacher F, Reuter S, Clémenty J Haïssaguerre M.Techniques, evaluation, and consequences of linear block at the left atrial roof in paroxysmal atrial fibrillation: a prospective randomized study. Circulation 2005;112:3688-3696. 13. Jais P, Hocini M, Hsu LF, Sanders P, Scavee C, Weerasooriya R, Macle L, Raybaud F, Garrigue S, Shah DC, Le Metayer P, Clémenty J, Haïssaguerre M. Technique and results of linear ablation at the mitral isthmus. Circulation 2004;110:2996-3002. 14. Haissaguerre M, Hocini M, Sanders P, Sacher F, Rotter M, Takahashi Y, Rostock T, Hsu LF, Bordachar P, Reuter S, Roudaut R, Clémenty J, Jaïs P. Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subsequent arrhythmias. J Cardiovasc Electrophysiol 2005;16:1138-1147. 15. Calo L, Lamberti F, Loricchio ML, De RE, Colivicchi F, Bianconi L, Pandozi C, Santini M. Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. J Am Coll Cardiol 2006;47:2504-2512. 16. Dixit S, Gerstenfeld EP, Callans DJ, Cooper JM, Lin D, Russo AM, Verdino RJ, Patel VV, Kimmel SE, Ratcliffe SJ, Hsia HH, Nayak HM, Zado E, Ren JF, Marchlinski FE Comparison of cool tip versus 8-mm tip catheter in achieving electrical isolation of pulmonary veins for long-term control of atrial fibrillation: a prospective randomized pilot study. J Cardiovasc Electrophysiol 2006;17:1074-1079. 17. Fassini G, Riva S, Chiodelli R, Trevisi N, Berti M, Carbucicchio C, Maccabelli G, Giraldi F, Bella PD. Left mitral isthmus ablation associated with PV isolation: long-term results of a prospective randomized study. J Cardiovasc Electrophysiol 2005;16:1150-1156. 18. Lim TW, Jassal IS, Ross DL, Thomas SP. Medium-term efficacy of segmental ostial pulmonary vein isolation for the treatment of permanent and persistent atrial fibrillation. Pacing Clin Electrophysiol 2006;29:374-379. 19. Oral H, Knight BP, Ozaydin M, Tada H, Chugh A, Hassan S, Scharf C, Lai SW, Greenstein R, Pelosi F Jr, Strickberger SA, Morady F . Clinical significance of early recurrences of atrial fibrillation after pulmonary vein isolation. J Am Coll Cardiol 2002;40:100-104. 20. Chugh A, Oral H, Lemola K, Hall B, Cheung P, Good E, Tamirisa K, Han J, Bogun F, Pelosi F Jr, Morady F. Prevalence, mechanisms, and clinical significance of macroreentrant atrial tachycardia during the following left atrial ablation for atrial fibrillation. Heart Rhythm 2005;2:464-471. 21. Callans DJ. Gerstenfeld EP, Dixit S, Zado E, Vanderhoff M, Ren JF, Marchiinski FE. Efficacy on repeat pulmonary vein isolation procedures in patients with recurrent atrial fibrillation. J Cardiovasc Electrophysiol 2004;15:1050-1055. 22. Saad EB, Rossillo A, Saad CP, Martin DO, Bhargava M, Erciyes D, Bash D, Williams-Andrews M, Beheiry S, Marrouche NF, Adams J, Pisanò E, Fanelli R, Potenza D, Raviele A, Bonso A, Themistoclakis S, Brachmann J, Saliba WI, Schweikert RA, Natale A. Pulmonary vein stenosis after radiofrequency ablation of atrial fibrillation: functional characterization, evolution, and influence of the ablation strategy. Circulation 2003;108:3102-3107. 23. Dong J, Vasamreddy CR, Jayam V, Dalal D, Dickfeld T, Eldadah Z, Meininger G, Halperin HT, Berger R, Bluemke DA, Calkins H. Incidence and predictors of pulmonary vein stenosis following catheter ablation of atrial fibrillation using the anatomic pulmonary vein approach: results from paired magnetic resonance imaging. J Cardiovasc Electrophysiol 2005;16:845-852. 24. Packer DL, Keelan P, Munger TM, Breen JF, Asirvatham S, Peterson LA, Monahan KH, Hauser MF, Chandrasedaran K, Sinak LJ, Holmes DR Jr. Clinical presentation, investigation, and management of pulmonary vein stenosis complicating ablation for atrial fibrillation. Circulation 2005;111:546-554. 25. Pappone C, Oral H, Santinelli V, Vicedomini G, Lang CC, 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 transcatheter ablation of atrial fibrillation. Circulation 2004;109:2724-2726. 26. Bai R, Patel D, Di BL, Fahmy TS, Kozeluhova M, Prasad S, Schweikert R, Cummings J, Saliba W, Andrews-Williams M, Themistoclakis S, Bonso A, Rossillo A, Raviele A, Schmitt C, Karch M, Uriarte JA, Tchou P, Arruda M, Natale A. Phrenic nerve injury after catheter ablation: should we worry about this complication? J Cardiovasc Electrophysiol 2006;17:944-948. 27. Sacher F, Monahan KH, Thomas SP, Davidson N, Adragao P, Sanders P, Hocini M, Takahashi Y, Rotter M, Rostock T, Hsu LF, Clémenty J, Haissaguerre M, Ross DL, Packer DL, Jaïs P. Phrenic nerve injury after atrial fibrillation catheter ablation: characterization and outcome in a multicenter study. J Am Coll Cardiol 2006;47:2498-2503. 28. Oral H, Chugh A, Ozaydin M, Good E, Fortino J, Sankaran S, Reich S, Igic P, Elmouchi D, Tschopp D, Wimmer A, Dey S, Crawford T, Pelosi F Jr, Jongnarangsin K, Bogun F, Morady F. Risk of thromboembolic events after percutaneous left atrial radiofrequency ablation of atrial fibrillation. Circulation 2006;17:1080-1085. 29. Waigand J, Uhlich F, Gross CM, Thalhammer C, Dietz R. Percutaneous treatment of pseudoaneurysms and arteriovenous fistulas after invasive vascular procedures. Catheter Cardiovasc Interv 1999;47:157-164. 30. Kuwahara T, Takahashi A, Kobori A, Miyazaki S, Takahashi Y, Takei A, Nozato T, Hikita H, Sato A, Aonuma K. Safe and effective ablation of atrial fibrillation: importance of esophageal temperature monitoring to avoid periesophageal nerve injury as a complication of pulmonary vein isolation. J Cardiovasc Electrophysiol. 2009;20:1-6. 31. Calkins H, Niklason L, Sousa J, el-Atassi R, Langberg J, Morady F. Radiation exposure during radiofrequency catheter ablation of accessory atrioventricular connections. Circulation 1991;84:2376-2382. 32. Kovoor P, Ricciardello M, Collins L, Uther JB, Ross DL. Risk to patients from radiation associated with radiofrequency ablation for supraventricular tachycardia. Circulation 1998;98:1534-1540. You may send an e-mail here should you wish to receive pubmed links to articles listed in reference.