Treatment Complications of Atrial Fibrillation and Their Management

Abstract

Atrial fibrillation (AF) is a rhythm disturbance defined by irregular, rapid electrical, and mechanical activation of the atria, which causes unsynchronized atrial contraction and promotes thromboembolism. AF is the most common sustained arrhythmia. Its prevalence and incidence are increasing due to aging and improved survival from acute heart diseases. This article is a review on AF management from both a surgical and catheter-based perspective. While both treatment approaches to AF have been shown to be successful in the management of AF, they are not without their own inherent complications. This article seeks to review some of these complications and help to guide treatment.

Keywords

atrial fibrillation - catheter ablation - arrhythmia surgery - complication management - arrhythmia management

• References

• 1 Camm AJ, Lip GY, De Caterina R. , et al; ESC Committee for Practice Guidelines-CPG; Document Reviewers. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association. Europace 2012; 14 (10) 1385-1413
• 2 Lloyd-Jones DM, Wang TJ, Leip EP. , et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation 2004; 110 (09) 1042-1046
• 3 Heeringa J, van der Kuip DA, Hofman A. , et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 2006; 27 (08) 949-953
• 4 Nattel S, Burstein B, Dobrev D. Atrial remodeling and atrial fibrillation: mechanisms and implications. Circ Arrhythm Electrophysiol 2008; 1 (01) 62-73
• 5 Olshansky B, Rosenfeld LE, Warner AL. , et al; AFFIRM Investigators. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study: approaches to control rate in atrial fibrillation. J Am Coll Cardiol 2004; 43 (07) 1201-1208
• 6 Calkins H, Kuck KH, Cappato R. , et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interv Card Electrophysiol 2012; 33 (02) 171-257
• 7 Haïssaguerre M, Jaïs P, Shah DC. , et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339 (10) 659-666
• 8 Arentz T, Haegeli L, Sanders P. , et al. High-density mapping of spontaneous pulmonary vein activity initiating atrial fibrillation in humans. J Cardiovasc Electrophysiol 2007; 18 (01) 31-38
• 9 Haegeli LM. CardioPulse. Percutaneous radiofrequency catheter ablation of atrial fibrillation. Eur Heart J 2012; 33 (21) 2625-2627
• 10 Haegeli LM, Kotschet E, Byrne J. , et al. Cardiac injury after percutaneous catheter ablation for atrial fibrillation. Europace 2008; 10 (03) 273-275
• 11 Haegeli LM, Wolber T, Ercin E. , et al. Double transseptal puncture for catheter ablation of atrial fibrillation: safety of the technique and its use in the outpatient setting. Cardiol Res Pract 2010; 2010: 295297
• 12 Gerstenfeld EP, Dixit S, Callans D. , et al. Utility of exit block for identifying electrical isolation of the pulmonary veins. J Cardiovasc Electrophysiol 2002; 13 (10) 971-979
• 13 Eitel C, Hindricks G, Sommer P. , et al. Circumferential pulmonary vein isolation and linear left atrial ablation as a single-catheter technique to achieve bidirectional conduction block: the pace-and-ablate approach. Heart Rhythm 2010; 7 (02) 157-164
• 14 Haegeli LM, Duru F, Lockwood EE. , et al. Feasibility and safety of outpatient radiofrequency catheter ablation procedures for atrial fibrillation. Postgrad Med J 2010; 86 (1017): 395-398
• 15 Eitel C, Koch J, Sommer P. , et al. Novel oral anticoagulants in a real-world cohort of patients undergoing catheter ablation of atrial fibrillation. Europace 2013; 15 (11) 1587-1593
• 16 Calkins H, Reynolds MR, Spector P. , et al. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses. Circ Arrhythm Electrophysiol 2009; 2 (04) 349-361
• 17 Noheria A, Kumar A, Wylie Jr JV, Josephson ME. Catheter ablation vs antiarrhythmic drug therapy for atrial fibrillation: a systematic review. Arch Intern Med 2008; 168 (06) 581-586
• 18 Cosedis Nielsen J, Johannessen A, Raatikainen P. , et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 2012; 367 (17) 1587-1595
• 19 Morillo CA, Verma A, Connolly SJ. , et al; RAAFT-2 Investigators. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. JAMA 2014; 311 (07) 692-700
• 20 Packer DL, Kowal RC, Wheelan KR. , et al; STOP AF Cryoablation Investigators. Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) pivotal trial. J Am Coll Cardiol 2013; 61 (16) 1713-1723
• 21 Hummel J, Michaud G, Hoyt R. , et al; TTOP-AF Investigators. Phased RF ablation in persistent atrial fibrillation. Heart Rhythm 2014; 11 (02) 202-209
• 22 Brooks AG, Stiles MK, Laborderie J. , et al. Outcomes of long-standing persistent atrial fibrillation ablation: a systematic review. Heart Rhythm 2010; 7 (06) 835-846
• 23 Nademanee K, McKenzie J, Kosar E. , et al. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol 2004; 43 (11) 2044-2053
• 24 Haïssaguerre M, Hocini M, Sanders P. , et al. Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subsequent arrhythmias. J Cardiovasc Electrophysiol 2005; 16 (11) 1138-1147
• 25 Haïssaguerre M, Sanders P, Hocini M. , et al. Catheter ablation of long-lasting persistent atrial fibrillation: critical structures for termination. J Cardiovasc Electrophysiol 2005; 16 (11) 1125-1137
• 26 Zado E, Callans DJ, Riley M. , et al. Long-term clinical efficacy and risk of catheter ablation for atrial fibrillation in the elderly. J Cardiovasc Electrophysiol 2008; 19 (06) 621-626
• 27 Ouyang F, Tilz R, Chun J. , et al. Long-term results of catheter ablation in paroxysmal atrial fibrillation: lessons from a 5-year follow-up. Circulation 2010; 122 (23) 2368-2377
• 28 Weerasooriya R, Khairy P, Litalien J. , et al. Catheter ablation for atrial fibrillation: are results maintained at 5 years of follow-up?. J Am Coll Cardiol 2011; 57 (02) 160-166
• 29 Cappato R, Calkins H, Chen SA. , et al. Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation 2005; 111 (09) 1100-1105
• 30 Cappato R, Calkins H, Chen SA. , et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 2010; 3 (01) 32-38
• 31 Cappato R, Calkins H, Chen SA. , et al. Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. J Am Coll Cardiol 2009; 53 (19) 1798-1803
• 32 Lee G, Sparks PB, Morton JB. , et al. Low risk of major complications associated with pulmonary vein antral isolation for atrial fibrillation: results of 500 consecutive ablation procedures in patients with low prevalence of structural heart disease from a single center. J Cardiovasc Electrophysiol 2011; 22 (02) 163-168
• 33 Kuwahara T, Takahashi A, Okubo K. , et al. Oesophageal cooling with ice water does not reduce the incidence of oesophageal lesions complicating catheter ablation of atrial fibrillation: randomized controlled study. Europace 2014; 16 (06) 834-839
• 34 Rostamian A, Narayan SM, Thomson L, Fishbein M, Siegel RJ. The incidence, diagnosis, and management of pulmonary vein stenosis as a complication of atrial fibrillation ablation. J Interv Card Electrophysiol 2014; 40 (01) 63-74 [PMID: 24626996 DOI: 10.1007/s10840-014-9885-z]
• 35 Holmes Jr DR, Monahan KH, Packer D. Pulmonary vein stenosis complicating ablation for atrial fibrillation: clinical spectrum and interventional considerations. JACC Cardiovasc Interv 2009; 2 (04) 267-276 [PMID: 19463436 DOI: 10.1016/j.jcin.2008.12.014]
• 36 Di Biase L, Fahmy TS, Wazni OM. , et al. Pulmonary vein total occlusion following catheter ablation for atrial fibrillation: clinical implications after long-term follow-up. J Am Coll Cardiol 2006; 48 (12) 2493-2499
• 37 Baranowski B, Saliba W. Our approach to management of patients with pulmonary vein stenosis following AF ablation. J Cardiovasc Electrophysiol 2011; 22 (03) 364-367
• 38 Jaïs P, Hocini M, Hsu LF. , et al. Technique and results of linear ablation at the mitral isthmus. Circulation 2004; 110 (19) 2996-3002
• 39 Holmes Jr DR, Nishimura R, Fountain R, Turi ZG. Iatrogenic pericardial effusion and tamponade in the percutaneous intracardiac intervention era. JACC Cardiovasc Interv 2009; 2 (08) 705-717
• 40 Michowitz Y, Rahkovich M, Oral H. , et al. Effects of sex on the incidence of cardiac tamponade after catheter ablation of atrial fibrillation: results from a worldwide survey in 34 943 atrial fibrillation ablation procedures. Circ Arrhythm Electrophysiol 2014; 7 (02) 274-280
• 41 Bunch TJ, Asirvatham SJ, Friedman PA. , et al. Outcomes after cardiac perforation during radiofrequency ablation of the atrium. J Cardiovasc Electrophysiol 2005; 16 (11) 1172-1179
• 42 Tokuda M, Kojodjojo P, Epstein LM. , et al. Outcomes of cardiac perforation complicating catheter ablation of ventricular arrhythmias. Circ Arrhythm Electrophysiol 2011; 4 (05) 660-666
• 43 O'Neill MD, Jaïs P, Derval N, Hocini M, Haïssaguerre M. Two techniques to avoid surgery for cardiac tamponade occurring during catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2008; 19 (03) 323-325
• 44 Neuberger HR, Tilz RR, Bonnemeier H. , et al. A survey of German centres performing invasive electrophysiology: structure, procedures, and training positions. Europace 2013; 15 (12) 1741-1746
• 45 Hammerstingl C, Lickfett L, Jeong K-M. , et al. Persistence of iatrogenic atrial septal defect after pulmonary vein isolation--an underestimated risk?. Am Heart J 2006; 152 (02) 362.e1-362.e5
• 46 Rillig A, Meyerfeldt U, Birkemeyer R, Treusch F, Kunze M, Jung W. Persistent iatrogenic atrial septal defect after pulmonary vein isolation: incidence and clinical implications. J Interv Card Electrophysiol 2008; 22 (03) 177-181
• 47 Chan N-Y, Choy C-C, Lau C-L. , et al. Persistent iatrogenic atrial septal defect after pulmonary vein isolation by cryoballoon: an under-recognized complication. Europace 2011; 13 (10) 1406-1410
• 48 Cronin EM, Collier P, Wazni OM, Griffin BP, Jaber WA, Saliba WI. Persistence of atrial septal defect after cryoballoon ablation of atrial fibrillation. J Am Coll Cardiol 2013; 62 (16) 1491-1492
• 49 Mugnai G, Sieira J, Ciconte G. , et al. One year incidence of atrial septal defect after PV isolation: a comparison between conventional radiofrequency and cryoballoon ablation. Pacing Clin Electrophysiol 2015; 38 (09) 1049-1057
• 50 Davies A, Gunaruwan P, Collins N, Barlow M, Jackson N, Leitch J. Persistent iatrogenic atrial septal defects after pulmonary vein isolation: long-term follow-up with contrast transesophageal echocardiography. J Interv Card Electrophysiol 2017; 48 (01) 99-103
• 51 Watanabe T, Miyazaki S, Kajiyama T. , et al. Persistence of an iatrogenic atrial septal defect after a second-generation cryoballoon ablation of atrial fibrillation. Heart Vessels 2018; 33 (09) 1060-1067
• 52 Linhart M, Werner JT, Stöckigt F. , et al. High rate of persistent iatrogenic atrial septal defect after single transseptal puncture for cryoballoon pulmonary vein isolation. J Interv Card Electrophysiol 2018; 52 (02) 141-148
• 53 Khakpour H, Shemin RJ, Lee JM. , et al. Atrioesophageal fistula after atrial fibrillation ablation: a single center series. J Atr Fibrillation 2017; 10 (03) 1654
• 54 Pappone C, Oral H, Santinelli V. , et al. Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation 2004; 109 (22) 2724-2726
• 55 Zellerhoff S, Ullerich H, Lenze F. , et al. Damage to the esophagus after atrial fibrillation ablation: just the tip of the iceberg? High prevalence of mediastinal changes diagnosed by endosonography. Circ Arrhythm Electrophysiol 2010; 3 (02) 155-159
• 56 Mohanty S, Santangeli P, Mohanty P. , et al. Outcomes of atrioesophageal fistula following catheter ablation of atrial fibrillation treated with surgical repair versus esophageal stenting. J Cardiovasc Electrophysiol 2014; 25 (06) 579-584
• 57 Stöllberger C, Pulgram T, Finsterer J. Neurological consequences of atrioesophageal fistula after radiofrequency ablation in atrial fibrillation. Arch Neurol 2009; 66 (07) 884-887
• 58 Eitel C, Rolf S, Zachäus M. , et al. Successful nonsurgical treatment of esophagopericardial fistulas after atrial fibrillation catheter ablation: a case series. Circ Arrhythm Electrophysiol 2013; 6 (04) 675-681
• 59 Ellis CR, Streur M, Scharf AW, Nesbitt JC. Successful treatment of esophageal perforation following atrial fibrillation ablation with a fully covered esophageal stent: prevention of atrial-esophageal fistula. J Innov Cardiac Rhythm Management 2012; 3: 874-878
• 60 Cox JL, Schuessler RB, Lappas DG, Boineau JP. An 8 1/2-year clinical experience with surgery for atrial fibrillation. Ann Surg 1996; 224 (03) 267-273 , discussion 273–275
• 61 Damiano Jr RJ, Gaynor SL, Bailey M. , et al. The long-term outcome of patients with coronary disease and atrial fibrillation undergoing the Cox maze procedure. J Thorac Cardiovasc Surg 2003; 126 (06) 2016-2021
• 62 Ad N, Suri RM, Gammie JS, Sheng S, O'Brien SM, Henry L. Surgical ablation of atrial fibrillation trends and outcomes in North America. J Thorac Cardiovasc Surg 2012; 144 (05) 1051-1060
• 63 Cox JL, Boineau JP, Schuessler RB, Jaquiss RD, Lappas DG. Modification of the maze procedure for atrial flutter and atrial fibrillation. I. Rationale and surgical results. J Thorac Cardiovasc Surg 1995; 110 (02) 473-484
• 64 Weimar T, Bailey MS, Watanabe Y. , et al. The Cox-maze IV procedure for lone atrial fibrillation: a single center experience in 100 consecutive patients. J Interv Card Electrophysiol 2011; 31 (01) 47-54
• 65 Weimar T, Schena S, Bailey MS. , et al. The cox-maze procedure for lone atrial fibrillation: a single-center experience over 2 decades. Circ Arrhythm Electrophysiol 2012; 5 (01) 8-14
• 66 Haensig M, Rastan AJ, Holzhey DM, Mohr FW, Garbade J. Surgical therapy of atrial fibrillation. Cardiol Res Pract 2012; 2012: 149503
• 67 Shah RU, Freeman JV, Shilane D, Wang PJ, Go AS, Hlatky MA. Procedural complications, rehospitalizations, and repeat procedures after catheter ablation for atrial fibrillation. J Am Coll Cardiol 2012; 59 (02) 143-149
• 68 Yong Ji S, Dewire J, Barcelon B. , et al. Phrenic nerve injury: an underrecognized and potentially preventable complication of pulmonary vein isolation using a wide-area circumferential ablation approach. J Cardiovasc Electrophysiol 2013; 24 (10) 1086-1091
• 69 Krul SP, Driessen AH, Zwinderman AH. , et al. Navigating the mini-maze: systematic review of the first results and progress of minimally-invasive surgery in the treatment of atrial fibrillation. Int J Cardiol 2013; 166 (01) 132-140
• 70 Kron J, Kasirajan V, Wood MA, Kowalski M, Han FT, Ellenbogen KA. Management of recurrent atrial arrhythmias after minimally invasive surgical pulmonary vein isolation and ganglionic plexi ablation for atrial fibrillation. Heart Rhythm 2010; 7 (04) 445-451
• 71 Zeng Y, Cui Y, Li Y. , et al. Recurrent atrial arrhythmia after minimally invasive pulmonary vein isolation for atrial fibrillation. Ann Thorac Surg 2010; 90 (02) 510-515
• 72 Gersak B, Kiser AC, Bartus K. , et al. Importance of evaluating conduction block in radiofrequency ablation for atrial fibrillation. Eur J Cardiothorac Surg 2012; 41 (01) 113-118
• 73 Castellá M, García-Valentín A, Pereda D. , et al. Anatomic aspects of the atrioventricular junction influencing radiofrequency Cox maze IV procedures. J Thorac Cardiovasc Surg 2008; 136 (02) 419-423
• 74 Gaita F, Riccardi R, Caponi D. , et al. Linear cryoablation of the left atrium versus pulmonary vein cryoisolation in patients with permanent atrial fibrillation and valvular heart disease: correlation of electroanatomic mapping and long-term clinical results. Circulation 2005; 111 (02) 136-142
• 75 Gillinov AM, Bhavani S, Blackstone EH. , et al. Surgery for permanent atrial fibrillation: impact of patient factors and lesion set. Ann Thorac Surg 2006; 82 (02) 502-513 , discussion 513–514
• 76 Phan K, Xie A, Tsai YC, Kumar N, La Meir M, Yan TD. Biatrial ablation vs. left atrial concomitant surgical ablation for treatment of atrial fibrillation: a meta-analysis. Europace 2015; 17 (01) 38-47
• 77 Barnett SD, Ad N. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. J Thorac Cardiovasc Surg 2006; 131 (05) 1029-1035
• 78 Badhwar V, Rankin JS, Damiano Jr RJ. , et al. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. Ann Thorac Surg 2017; 103 (01) 329-341
• 79 Ad N, Holmes SD, Shuman DJ, Pritchard G, Miller CE. Amiodarone after surgical ablation for atrial fibrillation: Is it really necessary? A prospective randomized controlled trial. J Thorac Cardiovasc Surg 2016; 151 (03) 798-803
• 80 Damiano Jr RJ, Schwartz FH, Bailey MS. , et al. The Cox maze IV procedure: predictors of late recurrence. J Thorac Cardiovasc Surg 2011; 141 (01) 113-121
• 81 Dresen W, Mason PK. Atrial flutter after surgical maze: incidence, diagnosis, and management. Curr Opin Cardiol 2016; 31 (01) 57-63
• 82 Philpott JM, Zemlin CW, Cox JL. , et al. The ABLATE trial: safety and efficacy of Cox maze-IV using a bipolar radiofrequency ablation system. Ann Thorac Surg 2015; 100 (05) 1541-1546 , discussion 1547–1548
• 83 Henn MC, Lancaster TS, Miller JR. , et al. Late outcomes after the Cox maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg 2015; 150 (05) 1168-1176 , 1178.e1–1178.e2
• 84 Soni LK, Cedola SR, Cogan J. , et al. Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation, but they do increase procedural morbidity. J Thorac Cardiovasc Surg 2013; 145 (02) 356-361 , discussion 361–363
• 85 Weimar T, Bailey MS, Watanabe Y. , et al. The Cox-maze IV procedure for lone atrial fibrillation: a single center experience in 100 consecutive patients. J Interv Card Electrophysiol 2011; 31 (01) 47-54
• 86 Lall SC, Melby SJ, Voeller RK. , et al. The effect of ablation technology on surgical outcomes after the Cox-maze procedure: a propensity analysis. J Thorac Cardiovasc Surg 2007; 133 (02) 389-396
• 87 Ad N, Holmes SD, Ali R, Pritchard G, Lamont D. A single center's experience with pacemaker implantation after the Cox maze procedure for atrial fibrillation. J Thorac Cardiovasc Surg 2017; 154 (01) 139-146.e1
• 88 Petrou A, Tzimas P, Siminelakis S. Massive bleeding in cardiac surgery. Definitions, predictors and challenges. Hippokratia 2016; 20 (03) 179-186
• 89 Prasad SM, Maniar HS, Camillo CJ. , et al. The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg 2003; 126 (06) 1822-1828
• 90 Millar RC, Arcidi Jr JM, Alison PJ. The maze III procedure for atrial fibrillation: should the indications be expanded?. Ann Thorac Surg 2000; 70 (05) 1580-1586
• 91 Chiappini B, Martìn-Suàrez S, LoForte A, Arpesella G, Di Bartolomeo R, Marinelli G. Cox/Maze III operation versus radiofrequency ablation for the surgical treatment of atrial fibrillation: a comparative study. Ann Thorac Surg 2004; 77 (01) 87-92
• 92 Lawrance CP, Henn MC, Miller JR, Sinn LA, Schuessler RB, Damiano Jr RJ. Comparison of the stand-alone Cox-Maze IV procedure to the concomitant Cox-Maze IV and mitral valve procedure for atrial fibrillation. Ann Cardiothorac Surg 2014; 3 (01) 55-61
• 93 Saint LL, Damiano Jr RJ, Cuculich PS. , et al. Incremental risk of the Cox-maze IV procedure for patients with atrial fibrillation undergoing mitral valve surgery. J Thorac Cardiovasc Surg 2013; 146 (05) 1072-1077