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Catheter Ablation Risks

All procedures have risks. The most common risk associated with catheter ablation is bruising or swelling at the puncture site. Other potential, but rarer, risks include blood clots and strokes (0% to 2%), phrenic nerve injury (0% to 0.4%), esophageal fistula (0.02% to 0.11%), pulmonary vein stenosis (<1%), and cardiac perforation (0.5% to 1%).¹

The first worldwide survey of catheter ablation, published in 2005, found a high number of complications, at 6%.² Since this data was from early catheter ablations, a higher rate of complications would be expected due to the “learning curve.” It is plausible that more complications occurred from early catheter ablations than later ones.

In the second worldwide survey of catheter ablation³, the overall major complications rate was lower, at 4.5% versus 6%² in the first survey. The rate of pulmonary vein stenosis, a significant narrowing of the pulmonary veins, was greatly reduced. That may be due to the movement from ablating inside the pulmonary veins to the outside of them. Other major complications included cardiac tamponade (a dangerous fluid buildup around the heart), transient ischemic attacks (TIAs), stroke, and death.

Data from the US analyzing an estimated 93,801 ablation procedures conducted from 2000 to 2010 found an overall complication rate of 6.29% and in-hospital mortality (death) rate of 0.46%.⁴ In this analysis, lower procedure volume by the doctor and hospital predicted complications, with hospitals doing fewer than 50 procedures per year associated with adverse outcomes.

Similarly, the first worldwide catheter ablation survey showed better outcomes at high-volume centers performing more than 100 procedures per year.²

Minimizing Catheter Ablation Risks

Many catheter ablation risks can be minimized¹ by newer ablation tools and technologies that alleviate patient risks caused by a lack of direct vision of the heart and radiation exposure from fluoroscopy during the procedure.

Here are tools and techniques that are being used to help minimize certain catheter ablation risks:

• Blood clots and stroke — Anticoagulation may be recommended before, during, and after catheter ablation to prevent a stroke or TIA from the catheter ablation.¹ If you are on an anticoagulant, you may be instructed to continue taking it throughout to help minimize your risk of bleeding and stroke. This is referred to as uninterrupted anticoagulation.  
• Esophageal fistula — Tools to move the esophagus during radiofrequency catheter ablation may prevent injuring the esophagus and creating an esophageal fistula. For example, a clinical study presented at the American College of Cardiology (ACC) Annual Scientific Sessions 2017 reported the safe use of an esophageal retractor (EsoSure) to move the esophagus away from the energy being delivered during ablation to avoid injury.⁵ Another approach involves using esophageal cooling (Attune Medical) during catheter ablation to prevent injuring the esophagus.
• Phrenic nerve injury — Cryoballoon ablation results in phrenic nerve injury more frequently than radiofrequency ablation. In the FIRE AND ICE trial, cryoballoon ablation was associated with more phrenic nerve injury than radiofrequency ablation (2.7% versus 0%), though most of these injuries were resolved within three months.⁶
• Cardiac perforation — Newer contact-force sensing catheters may lessen the risk of perforating cardiac tissue by determining the amount of pressure the catheter is exerting on heart tissue. To learn more about this technology, see Contact Force Sensing RF Catheters for Ablation.
• Pulmonary vein stenosis — Moving ablation from the opening of the pulmonary veins to an area outside of them has greatly reduced pulmonary vein stenosis. However, we sometimes hear at medical conferences that using contact-force sensing catheters may be leading to a resurgence of pulmonary vein stenosis. Because it has not been seen much in recent years, this complication may be underrecognized with doctors not using computed tomography (CT) scans or magnetic resonance imaging (MRI) to find it.⁷ Pulmonary vein stenosis can be mistaken for flu or bronchitis since it produces similar symptoms at three to six months.⁷ When detected early, it can easily be treated by inserting a stent into the pulmonary veins; however, if it goes undetected for a year or more, the veins may narrow and lead to serious complications. Thus, flu- or bronchitis-like symptoms following catheter ablation should be reported to your electrophysiologist to rule out pulmonary vein stenosis.

New techniques such as pulsed-field ablation, which has less collateral damage to nearby structures, may help minimize complications in the future. To learn more about minimizing risks of catheter ablation, see Catheter Ablation Techniques or Catheter Ablation Technology.

The StopAfib.org Video Library contains recordings of the catheter ablation presentations from our annual Get in Rhythm. Stay in Rhythm.^® Atrial Fibrillation Patient Conference where you can learn more about minimizing these complications.

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