Preventing Procedural Complications and Improving the Safety of AF Ablation

  • Tue, 4/26/11 - 4:39pm
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Blog by: Barbara Thomas, RN, FHRS

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting nearly 3 million people in the US and about 4.5 million in the European Union, with 600,000–800,000 new cases per year. This arrhythmia is associated with a high incidence of stroke, as well as symptoms that significantly affect the quality of life of the patient. Catheter ablation is recognized as an effective treatment to cure AF, but ablative therapy is associated with significant risks for the patient. The most significant risks include thrombus/char formation, pericardial effusion, and esophageal fistula. It is important to recognize the complications related to AF ablation and to take proactive steps to minimize these risks in order to provide the best possible outcome for the patient.

So what can we do to prevent the risks of complications during AF ablation? Here are some suggestions:

Patient management of anticoagulation
1. Preprocedure:
• Therapeutic INRs for three consecutive weeks preprocedure
• If the patient arrives in SR, no TEE is required

2. If the patient arrives in AFib with subtherapeutic INRs, they need a TEE

3. Peri-procedure:
• Achieve ACT > 300–350 sec with the first transseptal puncture
• ACT range during procedure should be 350–500 seconds
• Monitor ACTs every 20 minutes during the procedure

4. Anticoagulation post procedure:
• Maintain therapeutic INRs for at least 6 months post procedure

Intracardiac echo (ICE) during the procedure
1. Provides guidance for the transseptal puncture

2. Used for anatomical orientation

3. Allows for early detection of complications
• Thrombus
• Char
• Pericardial effusion

Preventing esophageal fistula
1. Constant monitoring of esophageal temperature with esophageal probe throughout the procedure

2. Remember: Temperature continues to increase after ablation is stopped

3. It is important to move the probe based on location of the ablation catheter

4. Maximum temperature = 39 degrees.

Barbara Thomas, RN, FHRS is the Director of Electrophysiology Services at the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center in Austin, Texas.

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