Incidence and Prevention of Cardiac Tamponade Complicating Ablation for Atrial Fibrillation

Abstract

Cardiac tamponade complicating catheter ablation of atrial fibrillation (AF) occurs in approximately 1% of pulmonary vein isolation (PVI), and up to 6% of linear ablation procedures. We reviewed 348 consecutive AF ablation (including repeat) procedures over 1 year, which all included PVI, with additional linear lesions at the mitral isthmus in 73%, and cavotricuspid isthmus (CTI) in 76%. An irrigated-tip ablation catheter was used, with power limited to 25-35 W for PVI and 45-60 W for linear lesions. Tamponade occurred in seven men and three women (2.9% of the population) during the creation of linear ablation lesions. Mechanical perforations occurred in two patients, and "popping" during radiofrequency (RF) energy delivery at the mitral isthmus in six, and at the CTI in two patients. Peak RF power was significantly higher in patients with than without tamponade (53 +/- 4 W vs 48 +/- 7 W; P = 0.02), and was greater than 48 W in all cases of "popping." In the following year, RF power for linear ablation was limited to </=42 W. Among 398 procedures, tamponade occurred in four patients (1.0%; P = 0.047 vs first year), three from "popping" and one from mechanical trauma. Procedural success rate remained the same despite reduction of power. Risk of tamponade was highest during linear ablation, mainly associated with high energy delivery and "popping." Reducing the energy limited, though did not eliminate this complication.

Catheter Ablation of Lone Atrial Fibrillation

“…The long procedure time, prolonged catheter manipulation in the LA, a higher energy output and ablation within the coronary sinus in order to achieve transmural lesion, may all increase the risk of perforation and embolism [135]. Interestingly, a systematic literature review (192 studies with 83.236 patients) did not find any significant relation of procedure duration, ablation time and ablation strategy with the occurrence of acute complications [124].…”

“…Gentle catheter manipulation in the LA and careful energy titration using irrigated-tip catheters could reduce the complication rate. In one study, 80% of myocardial perforations resulting in cardiac tamponade occurred during endocardial linear RF ablation of mitral isthmus and in 80% of cases popping phenomenon with impedance increase preceded the tamponade, while mechanical perforation of the LA was responsible for the remaining 20% of cardiac tamponade cases [135]. Energy reduction to ≤42W significantly reduced the cardiac tamponade rate from 2.9% to 1.0% (p=0.047).…”

“…Some authors proposed an alternative transcardiac approach to pericardial space with ongoing autotransfusion of evacuated blood in order to stabilize the patient before surgery [142]. However, the long-term prognosis after successful acute treatment of cardiac tamponade is very good and after complete rehabilitation, ablation procedure could be repeated [120,135,142]. Delayed cardiac tamponade, which occurs after an hour or more from the AF ablation (up to 50 days after the procedure) draws special attention.…”

Multiple Cardiac Perforations Following Radiofrequency Catheter Ablation: Case Report and Literature Reviews

“…Cardiac perforation of the left atrium that led to pericardial effusion and cardiac tamponade was reported by Hahn et al in 1995. 10) Cardiac rupture on the left ventricle after RFCA, requiring surgical repair was reported by Kino in 2005; the rupture was reported as starting from a small leak through the friable myocardium and gradually causing a blowing-out rupture.…”

Atrial Flutter, Typical and Atypical: A Review

“…100,101 Cardiac perforation secondary to tissue disruption by boiling with audible 'pops' can occur when high energy is delivered with large-tip catheter-electrodes. 102,103 A one in 1,000 incidence of cerebrovascular accidents is reported. 97 The recurrence rate of typical flutter is ≤10 % after successful CTI ablation and definitive flutter suppression can be attained by a second procedure in recurrent cases.…”