Επιπλοκές κατάλυσης πνευµονικών φλεβών

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1 Επιπλοκές κατάλυσης πνευµονικών φλεβών Παναγιώτης Ιωαννίδης Διευθυντής Τµήµατος Αρρυθµιών & Επεµβατικής Ηλεκτροφυσιολογίας Βιοκλινικής Αθηνών ΣΕΜΙΝΑΡΙΑ ΟΜΑΔΩΝ ΕΡΓΑΣΙΑΣ Ιωάννινα,

2 Solving an equation for each patient Interventional Risks Expected Benefits

3 Risk of complications Complex procedure High level anticoagulation Transseptal puncture Multiple venous access Complex LA manipulations Large amount of ablation lesions Thin atrial wall Surrounding structures

4 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation Complications of atrial fibrillation ablation Cardiac tamponade Pulmonary vein stenosis Esophageal injury/atrio-esophageal fistula Phrenic nerve injury Thrombo-embolism Air embolism Post-procedural arrhythmias Vascular complications Acute coronary artery occlusion Periesophageal vagal injury Radiation exposure during catheter ablation of atrial fibrillation Calkins et al. Europace 2007;9:

5 Studies were included if there were 100 patients in the treatment arm 83,236 patients!!! Gupta et al. Circ Arrhythm Electrophysiol. 2013;

6 Gupta et al. Circ Arrhythm Electrophysiol. 2013;

7 Gupta et al. Circ Arrhythm Electrophysiol. 2013;

8 Cardiac Tamponade The most common life-threatening acute complication seen in patients undergoing AF ablation (1,31% In the worldwide survey) Precipitating factors: overheating during energy delivery, extensive intracardiac ablation, inelegant catheter manipulation, incorrect transseptal puncture Treatment: Immediate percutaneous drainage is almost always sufficient. Surgical approach is necessary if accumulation of blood continues

9 Cardiac Tamponade The most common life-threatening acute complication seen in patients undergoing AF ablation (1,31% In the worldwide survey) Precipitating factors: overheating during energy delivery, extensive intracardiac ablation, inelegant catheter manipulation, incorrect transseptal puncture Treatment: Immediate percutaneous drainage is almost always sufficient. Surgical approach is necessary if accumulation of blood continues

10 19 EP centers 34,943 ablation procedures (72% men) 289 (0.9%) cases of tamponade 120 (1.24%) in women and 169 (0.67%) in men Michowitz et al. Circ Arrhythm Electrophysiol. 2014;7:

11 19 EP centers 34,943 ablation procedures (72% men) 289 (0.9%) cases of tamponade 120 (1.24%) in women and 169 (0.67%) in men * No relation was found concerning the use of ICE or the power settings and duration Michowitz et al. Circ Arrhythm Electrophysiol. 2014;7:

12 19 EP centers 34,943 ablation procedures (72% men) 289 (0.9%) cases of tamponade 120 (1.24%) in women and 169 (0.67%) in men Michowitz et al. Circ Arrhythm Electrophysiol. 2014;7:

13 19 EP centers 34,943 ablation procedures (72% men) 289 (0.9%) cases of tamponade 120 (1.24%) in women and 169 (0.67%) in men Michowitz et al. Circ Arrhythm Electrophysiol. 2014;7:

14 Shurrab et al. Int J Cardiol. 2013;169:

15 Significant Variability in Contact Forces Kuck et al. Heart Rhythm 2012;9:18 23

16 Akca et al. Int J Cardiol. 2015;179:

17 Atrioesophageal Fistula: anatomic relationships Lemola et al. Circulation. 2004;110:

18 Anatomic Relations Between the Esophagus and Left Atrium Esophagus wall was <5 mm from the endocardium in 40% of specimens The thermal injury and subsequent inflammatory reaction can cause atrio-esophageal fistula Quintana et al. Circulation. 2005;112:

19 Clinical Characteristics of Patients With Atrioesophageal Fistula: Data From Published Reports

20 Atrioesophageal Fistula Causes of death include cerebral air embolism, massive gastrointestinal bleeding, and septic shock. Mortality ranges from 71% to 83% Diagnosis Esophagram with thin barium, CT scan Endoscopy and transesophageal echocardiography should be avoided, as they may increase fistula size and the risk of food or air embolism Treatment : currently no standard treatment esophageal stenting, and direct intracardiac or transthoracic extracardiac surgical repair with or without cardiopulmonary bypass Prevention: Reducing the RF power when ablating the LA posterior wall with continuous catheter movement, monitoring esophageal temperature

21 60 year-old male with persistent AF and history of gastrectomy

22 60 year-old male with persistent AF and history of gastrectomy

23 60 year-old male with persistent AF and history of gastrectomy

24 Kawasaki et al. J Cardiovasc Electrophysiol 2014;25:

25 PV Stenosis Symptoms of PV stenosis commonly occur 2-4 months after the procedure Unexplained cough, dyspnea, hemoptysis and recurrent pneumonia CT and MR are the most precise methods of identifying PV stenosis Treatment involves angioplasty and stenting

26 PV Stenosis Symptoms of PV stenosis commonly occur 2-4 months after the procedure Unexplained cough, dyspnea, hemoptysis and recurrent pneumonia CT and MR are the most precise methods of identifying PV stenosis Treatment involves angioplasty and stenting

27 PV Stenosis Symptoms of PV stenosis commonly occur 2-4 months after the procedure Unexplained cough, dyspnea, hemoptysis and recurrent pneumonia CT and MR are the most precise methods of identifying PV stenosis Treatment involves angioplasty and stenting

28 Phrenic Nerve Injury Incidence 18/3,755 patients, 0.48% Ablation of the right superior PV (n=12), superior vena cava (n=3), and LA appendage (n=2) were associated with PN injury Clinical presentation: dyspnea, cough, hiccups or asymptomatic Complete (66%) or partial (17%) recovery occurred in the majority (Sacher et al. J Am Coll Cardiol 2006; 47: )

29 Phrenic Nerve Injury Incidence 18/3,755 patients, 0.48% Ablation of the right superior PV (n=12), superior vena cava (n=3), and LA appendage (n=2) were associated with PN injury Clinical presentation: dyspnea, cough, hiccups or asymptomatic Complete (66%) or partial (17%) recovery occurred in the majority (Sacher et al. J Am Coll Cardiol 2006; 47: )

30 Phrenic Nerve Injury Incidence 18/3,755 patients, 0.48% Ablation of the right superior PV (n=12), superior vena cava (n=3), and LA appendage (n=2) were associated with PN injury Clinical presentation: dyspnea, cough, hiccups or asymptomatic Complete (66%) or partial (17%) recovery occurred in the majority (Sacher et al. J Am Coll Cardiol 2006; 47: )

31 Thromboembolism Usually occurs within 24 h with the high-risk period extending up to 2 weeks Proposed mechanisms: Thrombus development on the sheath, char and thrombus formation in LA, and disruption of preexisting thrombus Warfarin should be continued for at least 2 months in all patients. Discontinuation of warfarin was not recommended in patients for CHADS 2 The use of open irrigated-tip catheters significantly reduced thromboembolic events

32 Santangeli et al. Circ Arrhythm Electrophysiol. 2012;5:

33 Santangeli et al. Circ Arrhythm Electrophysiol. 2012;5:

34 Santangeli et al. Circ Arrhythm Electrophysiol. 2012;5:

35 Santangeli et al. Circ Arrhythm Electrophysiol. 2012;5:

36 Santangeli et al. Circ Arrhythm Electrophysiol. 2012;5:

37 Kuwahara et al. J Cardiovasc Electrophysiol, 2013;24:

38 INR<2 Kuwahara et al. J Cardiovasc Electrophysiol, 2013;24:

39 *INR=1.6 *INR=1.7 Di Biase et al. Circulation 2014;129:

40 Cumulative Data from pts undergone AF Ablation on uninterrupted Warfarin 6,400 pts Santangeli et al. Circ Arrhythm Electrophysiol. 2012;5: (Meta-ananlysis) 1,327 pts Kuwahara et al. J Cardiovasc Electrophysiol, 2013;24: pts Di Biase et al. Circulation 2014;129: Total >8,500 pts Strokes on therapeutic INR 0

41 Page et al. Cardiovasc J Electrophysiol 2014;25:

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