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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.
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