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Circ Arrhythm Electrophysiol 2013; 6:754. https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 26/32 7/6/23, 2:50 PM Atrial fibrillation: Catheter ablation - UpToDate Topic 949 Version 66.0 https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 27/32 7/6/23, 2:50 PM Atrial fibrillation: Catheter ablation - UpToDate GRAPHICS Signs and symptoms of complications of catheter ablation to prevent atrial fibrillation within a month post-ablation Sign/symptom Differential Suggested evaluation Back pain Musculoskeletal, retroperitoneal hematoma Physical exam, CT imaging Chest pain Pericarditis, pericardial effusion, Physical exam, chest coronary stenosis (ablation radiograph, ECG, related), pulmonary vein stenosis, musculoskeletal (after echocardiogram, stress test, cardiac catheterization, chest CT cardioversion), worsening reflux Cough Infectious process, bronchial irritation (mechanical, Physical exam, chest radiograph, chest CT cryoballoon), pulmonary vein stenosis Dysphagia Esophageal irritation (related to Physical exam, chest CT, MRI transesophageal echocardiography), atrioesophageal fistula Early satiety, nausea Gastric denervation Physical exam, gastric emptying study Fever Infectious process, pericarditis, atrioesophageal fistula Physical exam, chest radiograph, chest CT, urinalysis, laboratory blood work Fever, dysphagia, neurological symptoms Atrial esophageal fistula Physical exam, laboratory blood work, chest CT or MRI; avoid endoscopy with air insufflation Groin pain Pseudoaneurysm, AV fistula, hematoma Ultrasound of the groin, laboratory blood work; consider CT scan if ultrasound negative Hypotension Pericardial effusion/tamponade, bleeding, sepsis, persistent Echocardiography, laboratory blood work vagal reaction Hemoptysis Pulmonary vein stenosis or Chest radiograph, chest CT or occlusion, pneumonia MR scan, VQ scan Neurological symptoms Cerebral embolic event, atrial Physical exam, brain imaging, esophageal fistula chest CT or MRI https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 28/32 7/6/23, 2:50 PM Atrial fibrillation: Catheter ablation - UpToDate Shortness of breath Volume overload, pneumonia, Physical exam, chest pulmonary vein stenosis, radiograph, chest CT, laboratory phrenic nerve injury blood work CT: computed tomography; ECG: electrocardiogram; MRI: magnetic resonance imaging; AV: atrioventricular. Adapted from: Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial brillation: Executive summary. J Interv Card Electrophysiol 2017; 50:1. Available at: https://link.springer.com/article/10.1007%2Fs10840-017-0277-z. Copyright 2017 The Authors. Reproduced under the terms of the Creative Commons Attribution License 4.0. Graphic 127127 Version 1.0 https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 29/32 7/6/23, 2:50 PM Atrial fibrillation: Catheter ablation - UpToDate Intraprocedural risks of ablation for atrial fibrillation Complication Incidence Diagnostic testing Air embolism <1% Nothing or cardiac catheterization Asymptomatic cerebral emboli 2 to 15% Brain MRI Cardiac tamponade 0.2 to 5% Echocardiography Coronary stenosis/occlusion <0.1% Cardiac catheterization Death <0.1 to 0.4% N/A Mitral valve entrapment <0.1% Echocardiography Permanent phrenic nerve paralysis 0 to 0.4% Chest radiograph, sniff test Radiation injury <0.1% None Stroke or TIA 0 to 2% Head CT/MRI, cerebral angiography Vascular complications 0.2 to 1.5% Vascular ultrasound, CT scan MRI: magnetic resonance imaging; TIA: transient ischemic attack; CT: computed tomography. Adapted from: Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial brillation: Executive summary. J Interv Card Electrophysiol 2017; 50:1. Available at: https://link.springer.com/article/10.1007%2Fs10840-017-0277-z. Copyright 2017 The Authors. Reproduced under the terms of the Creative Commons Attribution License 4.0. Graphic 127125 Version 1.0 https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 30/32 7/6/23, 2:50 PM Atrial fibrillation: Catheter ablation - UpToDate CHADS score, thromboembolic risk, and effect of warfarin anticoagulation 2 Clinical parameter Points Congestive heart failure (any history) 1 Hypertension (prior history) 1 Age 75 years 1 Diabetes mellitus 1 Secondary prevention in patients with a prior ischemic stroke or a transient 2 ischemic attack; most experts also include patients with a systemic embolic event Events per 100 person-years* CHADS score 2 NNT Warfarin No warfarin 0 0.25 0.49 417 1 0.72 1.52 125 2 1.27 2.50 81 3 2.20 5.27 33 4 2.35 6.02 27 5 or 6 4.60 6.88 44 NNT: number needed to treat to prevent 1 stroke per year with warfarin. The CHADS score estimates the risk of stroke, which is defined as focal neurologic signs or symptoms that persist for more than 24 hours and that cannot be explained by hemorrhage, trauma, 2 or other factors, or peripheral embolization, which is much less common. Transient ischemic attacks are not included. All differences between warfarin and no warfarin groups are statistically significant, except for a trend with a CHADS score of 0. Patients are considered to be at low risk with a score of 0, at intermediate risk with a score of 1 or 2, and at high risk with a score 3. One exception is that most experts would consider patients with a prior ischemic stroke, transient ischemic attack, or 2 systemic embolic event to be at high risk, even if they had no other risk factors and, therefore, a score of 2. However, the great majority of these patients have some other risk factor and a score of at least 3. Data from: Go AS, Hylek EM, Chang Y, et al. Anticoagulation therapy for stroke prevention in atrial brillation: how well do randomized trials translate into clinical practice? JAMA 2003; 290:2685; and CHADS2 score from Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classi cation schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285:2864. Graphic 61615 Version 8.0 https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 31/32 7/6/23, 2:50 PM Atrial fibrillation: Catheter ablation - UpToDate Contributor Disclosures Rod Passman, MD, MSCE Grant/Research/Clinical Trial Support: Abbott [Ablation]; AHA [Ablation]; NIH [Stroke prevention]. Consultant/Advisory Boards: Abbott [Ablation]; iRhythm [Monitoring]; Janssen [Atrial fibrillation detection]; Medtronic [Implantable cardiac monitors]. Speaker's Bureau: iRhythm [Monitoring]. All of the relevant financial relationships listed have been mitigated. Bradley P Knight, MD, FACC Grant/Research/Clinical Trial Support: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; MDT [Electrophysiology]; Philips [Electrophysiology]. Consultant/Advisory Boards: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; CVRx [Heart failure]; MDT [Electrophysiology]; Philips [Electrophysiology]; Sanofi [Arrhythmias]. Speaker's Bureau: Abbott [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Transeptal catheterization]; BSCI [Electrophysiology]; MDT [Electrophysiology]. All of the relevant financial relationships listed have been mitigated. N A Mark Estes, III, MD Consultant/Advisory Boards: Boston Scientific [Arrhythmias]; Medtronic [Arrhythmias]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/atrial-fibrillation-catheter-ablation/print 32/32