1. Complications of Ablation of Atrial Fibrillation How to Prevent and to Treat Complications of Ablation of Atrial Fibrillation How to Prevent and to Treat Yong-Mei Cha, MD Mayo Clinic, Rochester, MN GW-ICC 2005, Beijing

2. Incidence of complications Mayo Clinic AF ablation 1999-2004N=623 Mayo Clinic AF ablation 1999-2004N=623 Pericardial effusion 70 (11%) Pericardial effusion 70 (11%) Tamponade 15 (2.4%) Stroke/TIA5 (0.8%) Stroke/TIA5 (0.8%) Phrenic nerve injury5 (0.8%) Phrenic nerve injury5 (0.8%) Pulmonary vein stenosis 20 (3.2%) Pulmonary vein stenosis 20 (3.2%) Myocardial infarction2 (0.3%) Myocardial infarction2 (0.3%) Valve injury1 (0.2%) Valve injury1 (0.2%) Groin hematoma14 (2.2%) Groin hematoma14 (2.2%) Atrioesophageal fistula? Atrioesophageal fistula?

3. Pericardial effusion and Tamponade Small pericardial effusion is common (11%) in wide area circumferential ablation due to extensive transmural lesions. Small pericardial effusion is common (11%) in wide area circumferential ablation due to extensive transmural lesions. Pericarditis is not uncommon, pleuritic chest pain. Pericarditis is not uncommon, pleuritic chest pain. Myocardial perforation and tamponade Myocardial perforation and tamponade Mayo 2.4%, Haissaguerre group 2.9% catheter induced mechanical perforation, 0.5% “popping” during energy delivery, 2.4% Small pericardial effusion is common (11%) in wide area circumferential ablation due to extensive transmural lesions. Small pericardial effusion is common (11%) in wide area circumferential ablation due to extensive transmural lesions. Pericarditis is not uncommon, pleuritic chest pain. Pericarditis is not uncommon, pleuritic chest pain. Myocardial perforation and tamponade Myocardial perforation and tamponade Mayo 2.4%, Haissaguerre group 2.9% catheter induced mechanical perforation, 0.5% “popping” during energy delivery, 2.4%

4. Pericardial Effusion

5. How to prevent myocardial perforation ♥Understand atrial anatomy ♥ Gentle catheter manipulation ♥ use 4 or 5mm catheter tip if possible ♥ Monitor arterial blood pressure continuously ♥ Monitor pericardial space by intracardiac echo ♥Understand atrial anatomy ♥ Gentle catheter manipulation ♥ use 4 or 5mm catheter tip if possible ♥ Monitor arterial blood pressure continuously ♥ Monitor pericardial space by intracardiac echo

6. How to manage pericardial effusion ♥ Small pericardial effusion: usually asymptomatic and do not require treatment ♥ Pericarditis: anti-inflammatory agent for a week to relieve chest pain ♥ Tamponade: requires emergency pericardiocentisis to drain hemapericardium Surgical myocardial repair is rarely required ♥ Small pericardial effusion: usually asymptomatic and do not require treatment ♥ Pericarditis: anti-inflammatory agent for a week to relieve chest pain ♥ Tamponade: requires emergency pericardiocentisis to drain hemapericardium Surgical myocardial repair is rarely required

7. Thromboembolic stroke Mayo Clinic, 5 patients, 0.8% Mayo Clinic, 5 patients, 0.8% Causes: Causes: ♥ preexisting left atrial clot ♥ new clot is formed during the ablation often on the sheath, lasso and ablation often on the sheath, lasso and ablation catheter catheter ♥ ablation lesion thrombosis 21/270 (8%) patients had thrombi, attached to: 21/270 (8%) patients had thrombi, attached to: EP catheter/sheath 17/21 Endocardial surface 5/21 Mayo Clinic, 5 patients, 0.8% Mayo Clinic, 5 patients, 0.8% Causes: Causes: ♥ preexisting left atrial clot ♥ new clot is formed during the ablation often on the sheath, lasso and ablation often on the sheath, lasso and ablation catheter catheter ♥ ablation lesion thrombosis 21/270 (8%) patients had thrombi, attached to: 21/270 (8%) patients had thrombi, attached to: EP catheter/sheath 17/21 Endocardial surface 5/21

9. Suction from the sheath

10. How to prevent stroke Pre-ablation: Pre-ablation: transesophageal echocardiogram to rule-out atrial thrombus During ablation: During ablation: intracardiac echocardiogram systemic and sheath heparinization Post-ablation: Post-ablation:coumadin Pre-ablation: Pre-ablation: transesophageal echocardiogram to rule-out atrial thrombus During ablation: During ablation: intracardiac echocardiogram systemic and sheath heparinization Post-ablation: Post-ablation:coumadin

11. During ablation: intracardiac echocardiogram ♦ facilitate transseptal puncture ♦ monitor clot and bubbles ♦ identify venoatrial junction ♦ monitor pericaridial effusion During ablation: intracardiac echocardiogram ♦ facilitate transseptal puncture ♦ monitor clot and bubbles ♦ identify venoatrial junction ♦ monitor pericaridial effusion How to prevent stroke

13. During Ablation Asystemic heparinization to maintain ACT 300-350 when catheters are in the left atrium after transseptal Bcontinuous heparinized saline infusion through transseptal sheaths Cif clot is formed on the catheter, remove the catheter and suck the sheath During Ablation Asystemic heparinization to maintain ACT 300-350 when catheters are in the left atrium after transseptal Bcontinuous heparinized saline infusion through transseptal sheaths Cif clot is formed on the catheter, remove the catheter and suck the sheath

14. How to prevent stroke Post-ablation Alow molecular weight heparin injection starting the next morning until INR ≥ 2.0 Bcoumadin starting the evening of ablation and for at least 3 months to prevent lesion thrombus Post-ablation Alow molecular weight heparin injection starting the next morning until INR ≥ 2.0 Bcoumadin starting the evening of ablation and for at least 3 months to prevent lesion thrombus

15. Phrenic nerve injury Uncommon, <1% Uncommon, <1% the right phrenic nerve has close proximity the right phrenic nerve has close proximity to the superior caval vein 0.3 mm to the right superior pulmonary vein 2.1 mm Uncommon, <1% Uncommon, <1% the right phrenic nerve has close proximity the right phrenic nerve has close proximity to the superior caval vein 0.3 mm to the right superior pulmonary vein 2.1 mm

17. Phrenic Stimulation Site RSPV

18. Post-ablation Pre-ablation Right hemidiaphragm paralysis

19. How to prevent phrenic nerve injury ♥Be cautious when ablate right superior pulmonary vein ♥ High output pacing from ablation catheter before delivering the energy. ♥Be cautious when ablate right superior pulmonary vein ♥ High output pacing from ablation catheter before delivering the energy.

20. Pulmonary vein stenosis The lesion is characterized by intimal thickening, thrombus formation, endocardial contraction, and proliferation of elastic laminae The lesion is characterized by intimal thickening, thrombus formation, endocardial contraction, and proliferation of elastic laminae

21. Diagnosis of PV stenosis The mean onset of symptoms is two to five months after the procedure The mean onset of symptoms is two to five months after the procedure Progressive dyspnea on exertion, orthopnea, Intermittent cough, hemoptysis Progressive dyspnea on exertion, orthopnea, Intermittent cough, hemoptysis Chest CT: pulmonary vein narrowing Chest CT: pulmonary vein narrowing Echo Doppler: increased PV flow velocity Echo Doppler: increased PV flow velocity VQ Scan: Markedly reduced lung perfusion VQ Scan: Markedly reduced lung perfusion The mean onset of symptoms is two to five months after the procedure The mean onset of symptoms is two to five months after the procedure Progressive dyspnea on exertion, orthopnea, Intermittent cough, hemoptysis Progressive dyspnea on exertion, orthopnea, Intermittent cough, hemoptysis Chest CT: pulmonary vein narrowing Chest CT: pulmonary vein narrowing Echo Doppler: increased PV flow velocity Echo Doppler: increased PV flow velocity VQ Scan: Markedly reduced lung perfusion VQ Scan: Markedly reduced lung perfusion

24. Pre ablation Post ablation LIPV stenosis

25. How to prevent PV stenosis ♥PV venogram may help to identify venoatrial junction ♥ Intracardiac echocardiography monitor PV flow velocity ♥ Ablate outside of PV orifice ♥ RF power ≤ 30W, Temperature ≤ 50 ºC ♥ Fewer burns in small pulmonary veins ♥PV venogram may help to identify venoatrial junction ♥ Intracardiac echocardiography monitor PV flow velocity ♥ Ablate outside of PV orifice ♥ RF power ≤ 30W, Temperature ≤ 50 ºC ♥ Fewer burns in small pulmonary veins

26. RSPV

27. ICE guidance

28. How to manage pulmonary vein stenosis Mild to moderate pulmonary narrowing ≤50%: observation Mild to moderate pulmonary narrowing ≤50%: observation Moderate to severe PV stenosis: close follow-up, chest CT in 3 months Moderate to severe PV stenosis: close follow-up, chest CT in 3 months Severe PV stenosis ≥90%: PV dilation and stenting. Severe PV stenosis ≥90%: PV dilation and stenting. Mild to moderate pulmonary narrowing ≤50%: observation Mild to moderate pulmonary narrowing ≤50%: observation Moderate to severe PV stenosis: close follow-up, chest CT in 3 months Moderate to severe PV stenosis: close follow-up, chest CT in 3 months Severe PV stenosis ≥90%: PV dilation and stenting. Severe PV stenosis ≥90%: PV dilation and stenting.

29. Pulmonary Vein Stenting

31. LSPV 45/25 (mean=24)LSPV 23/12 (mean=17) Mean LA = 8Mean LA = 9  P = 16  P = 8

34. Atrioesophageal fistula Incidence? Fatal Incidence? Fatal Esophagitis: Heartburn, midsternal pain Esophagitis: Heartburn, midsternal pain Bacteremia: fever, chills, Bacteremia: fever, chills, Thromboembolism or air embolism: neurological deficit Thromboembolism or air embolism: neurological deficit Massive gastrointestinal bleeding Massive gastrointestinal bleeding Incidence? Fatal Incidence? Fatal Esophagitis: Heartburn, midsternal pain Esophagitis: Heartburn, midsternal pain Bacteremia: fever, chills, Bacteremia: fever, chills, Thromboembolism or air embolism: neurological deficit Thromboembolism or air embolism: neurological deficit Massive gastrointestinal bleeding Massive gastrointestinal bleeding

35. Lemola et al, Circ 2004

37. 40% 20% Lemola et al, Circ 2004 40% Relationship of esophagus to posterior LA wall: 3D CT images

39. How to prevent atrioesophageal fistula ♥Placing esophageal probe and knowing the anatomic course of the esophagus under fluoroscopy ♥ Tagging the anatomical relationship of esophagus and left atrium on CARTO map ♥ measuring esophageal temperature during ablation ♥ Monitoring microbubbles to adjust RF power ♥Placing esophageal probe and knowing the anatomic course of the esophagus under fluoroscopy ♥ Tagging the anatomical relationship of esophagus and left atrium on CARTO map ♥ measuring esophageal temperature during ablation ♥ Monitoring microbubbles to adjust RF power

40. AF ablation CP1121662-7 Elimination of AF 70-80% 70-80% Complications6-8%Complications6-8% Weigh benefit and adverse effects

41. Ablation paradigm in CHF patients Circumferential PV isolation n=19 Wide area LA ablation n=9

42. Wide area LA ablation (PA view) RSPV LSPV RIPV LSPV

46. PV ostia located with aid of ICE and accessed using Multipurpose catheter advanced via Mullins sheath into LA PV ostia located with aid of ICE and accessed using Multipurpose catheter advanced via Mullins sheath into LA Pressure gradient measured using catheters and Doppler velocity signals Pressure gradient measured using catheters and Doppler velocity signals Pulmonary venography Pulmonary venography Pulmonary Vein Stenting