Table 10.
Major complications of ventricular arrhythmia ablation in patients with structural heart disease
| Complication | Incidence | Mechanisms | Presentation | Prevention | Treatment | Ref. |
|---|---|---|---|---|---|---|
| In-hospital mortality | 0%–3% | VT recurrence, heart failure, complications of catheter ablation | Not applicable | Correct electrolyte disturbances and optimize medical status before ablation | — | S10.2.1–S10.2.5 |
| Long-term mortality | 3%–35% (12–39 months of follow-up) | VT recurrence and progression of heart failure | Cardiac nonarrhythmic death (heartfailure) and VT recurrence | Identification of patients with indication for heart transplantation | — | S10.2.2–S10.2.5 |
| Neurological complication (stroke, TIA, cerebral hemorrhage) | 0%–2.7% | Emboli from left ventricle, aortic valve, or aorta; cerebral bleeding | Focal or global neurological deficits | Careful anticoagulation control; ICE can help detection of thrombus formation, and of aortic valve calcification; TEE to assess aortic arch | Thrombolytic therapy | S10.2.1–S10.2.5 |
| Pericardial complications: cardiac tamponade, hemopericardium, pericarditis | 0%–2.7% | Catheter manipulation, RF delivery, epicardial perforation | Abrupt or gradual fall in blood pressure; arterial line is recommended in ablation of complex VT | Contact force can be useful, careful in RF delivery in perivenous foci and RVOT | Pericardiocentesis; if necessary, surgical drainage, reversal heparin; steroids and colchicine in pericarditis | S10.2.1–S10.2.5 |
| AV block | 0%–1.4% | Energy delivery near the conduction system | Fall in blood pressure and ECG changes | Careful monitoring when ablation is performed near the conduction system; consider cryoablation | Pacemaker; upgrade to a biventricular pacing device might be necessary | S10.2.1–S10.2.4 |
| Coronary artery damage/MI | 0.4%–1.9% | Ablation near coronary artery, unintended coronary damage during catheter manipulation in the aortic root or crossing the aortic valve | Acute coronary syndrome; confirmation with coronary catheterization | Limit power near coronary arteries and avoid energy delivery <5 mm from coronary vessel; ICE is useful to visualize the coronary ostium | Percutaneous coronary intervention | S10.2.1–S10.2.5 |
| Heart failure/pulmonary edema | 0%–3% | External irrigation, sympathetic response due to ablation, and VT induction | Heart failure symptoms | Urinary catheter and careful attention to fluid balance and diuresis, optimize clinical status before ablation, reduce irrigation volume if possible (decrease flow rates or use closed irrigation catheters) | New/increased diuretics | S10.2.2–S10.2.5 |
| Valvular injury | 0%–0.7% | Catheter manipulation, especially retrograde crossing the aortic valve and entrapment in the mitral valve; energy delivery to subvalvular structures, including papillary muscle | Acute cardiovascular collapse, new murmurs, progressive heart failure symptoms | Careful catheter manipulation; ICE can be useful for identification of precise location of energy delivery | Echocardiography is essential in the diagnosis; medical therapy, including vasodilators and dobutamine before surgery; IABP is useful in acute mitral regurgitation and is contraindicated in aortic regurgitation | S10.2.2–S10.2.5 |
| Acute periprocedural hemodynamic decompensation, cardiogenic shock | 0%–11% | Fluid overloading, general anesthesia, sustained VT | Sustained hypotension despite optimized therapy | Close monitoring of fluid infusion and hemodynamic status -Optimize medical status before ablation -pLVAD -Substrate mapping preferred, avoid VT induction in higher-risk patients |
Mechanical HS | S10.2.2–S10.2.6 |
| Vascular injury: hematomas, pseudoaneurysm, AV fistulae | 0%–6.9% | Access to femoral arterial and catheter manipulation | Groin hematomas, groin pain, fall in hemoglobin | Ultrasound-guided access | Ultrasound-guided compression, thrombin injection, and surgical closure | S10.2.1–S10.2.5 |
| Overall major complications with SHD | 3.8%–11.24% | S10.2.1–S10.2.5 | ||||
| Overall all complications | 7%–14.7% | S10.2.3,S10.2.7,S10.2.8 |
AV = atrioventricular; ECG = electrocardiogram; HS = hemodynamic support; IABP = intra-aortic balloon pump; ICE = intracardiac echocardiography; MI = myocardial infarction; pLVAD = percutaneous left ventricular assist device; RF = radiofrequency; RVOT = right ventricular outflow tract; SHD = structural heart disease; TEE = transesophageal echocardiography; TIA = transient ischemic attack; VT = ventricular tachycardia.