Table 3.
Procedural Complications
| Complication | Prevention | Diagnosis | Treatment |
|---|---|---|---|
| EP catheter procedural complications | |||
| Pericardial effusion/tamponade | Avoid excess catheter force | Fluoroscopy of cardiac border,63 2D echocardiography | Reversal of anticoagulation, urgent pericardiocentesis |
| AV nodal block | Monitor for accelerated junctional rhythm, VA block, AV block during overdrive atrial pacing | ECG | Pacemaker |
| Phrenic nerve palsy | Phrenic nerve mapping, phrenic nerve pacing during RSPV, SVC, and LAA ablation64, 65, 66 | Fluoroscopy, chest radiography | Conservative therapy |
| Stroke | Anticoagulation (ACT >300 or 350 s in the LA), avoid char formation | Neurological exam, MRI scan (DWI and FLAIR imaging) | Conservative therapy, Merci thrombectomy |
| Coronary artery injury | Avoid excess power delivery in the CS, coronary angiography before epicardial ablation, coronary ostia visualization by angiography and ICE before ablation in the aortic root | ECG | Percutaneous intervention |
| Access site complications (hematoma, AV fistula, pseudoaneurysm) | Site selection, excellent technique, vascular ultrasound to guide puncture,67 micropuncture | Physical exam, ultrasound | Manual pressure, bed rest |
| Radiation burn | Minimize radiation exposure | Physical exam (presentation typically 2–8 wk postprocedure, but can be >40 wk) | Avoid repeat exposure |
| CIED implant procedural complications | |||
| Pneumothorax | Extrathoracic vascular access (axillary or cephalic vein) | Chest radiography | 100% oxygen rebreather, chest tube |
| Lead dislodgement | Test lead for acute fixation (“tug test”) | ECG, device interrogation, chest radiography | Reoperation and repositioning |
| Pericardial effusion/tamponade | Avoid excess forward pressure during lead placement | Fluoroscopy of the cardiac border,63 2D echocardiography | Urgent pericardiocentesis |
| Pocket hematoma | Avoid heparin and clopidogrel | Exam | Conservative therapy, pressure wrap, reoperation for pocket evacuation |
| Infection | Preoperative antibiotics, prevent hematoma,67 score or excise chronic pocket fibrosis | Exam, wound culture, blood culture | Antibiotics, extraction of the entire system (unless superficial) |
| Air embolism | Use introducer sheaths with hemostatic valves | Fluoroscopy | 100% oxygen rebreather |
| Postprocedural complications | |||
| Hematoma | Avoid heparin and clopidogrel | Exam | Conservative therapy |
| Infection | Good wound care | Exam, wound culture, blood culture | Antibiotics, extraction of entire system (unless superficial) |
| Late pericardial effusion/tamponade | None | 2D echocardiography | Pericardiocentesis |
| Phrenic nerve palsy | Phrenic nerve mapping, phrenic nerve pacing during RSPV, SVC, and LAA ablation64, 65, 66 | Loss of diaphragmatic motion on fluoroscopy, elevated hemidiaphragm | Conservative therapy |
| Stroke | Postprocedure anticoagulation68 | Neurological exam, MRI scan (DWI and FLAIR imaging) | Conservative therapy, consider Merci thrombectomy |
| Myocardial infarction | Appropriate anticoagulation | ECG, biomarkers | Medical therapy, percutaneous intervention |
| Atrial-esophageal fistula | Limit power, time, temperature, pressure during posterior wall ablation, monitor esophageal temperature | Fever, malaise, leukocytosis, systemic embolism, CT or MRI findings | Surgery |
| New arrhythmias | Avoid creation of gaps in linear ablation | ECG, ambulatory monitor | Antiarrhythmic drugs, repeat catheter ablation |
| Radiation burn | Minimize radiation exposure | Physical exam (presentation typically 2–8 wk postprocedure, but can be >40 wk) | Avoid repeat exposure |
2D = two-dimensional; ACT = activated clotting time; AV = atrioventricular; CS = coronary sinus; CT = computed tomography; DWI = diffusion weighted imaging; ECG = electrocardiogram; EP = electrophysiology; FLAIR = fluid-attenuated inversion recovery; ICE = intracardiac echocardiography; LA = left atrium; LAA = left atrial appendage; MRI = magnetic resonance imaging; RSPV = right superior pulmonary vein; SVC = superior vena cava; VA = ventricular atrial.