khrs 2019 june 21, 2019k-hrs.org/khrs/2019_2/serious complications of af... · 2019-07-04 · after...

Serious Complications after AF Ablation

Jaemin Shim, MD, PhD

Arrhythmia Center,

Korea University Anam Hospital, Seoul, Korea

June 21, 2019KHRS 2019

KOREA UNIVERSITY MEDICAL CENTER

Contents

Atrioesophageal Fistula

Electrical Isolation of LAA

Delayed Activation of LAA


Types of Complications Rate (%)

Cardiac Tamponade 0.5-2

Stroke/TIA 0.3-1

Vascular injury 0.5-2

PV stenosis <1

Phrenic nerve palsy 0.2

Atrial-esophageal fistula <0.1%

Death <0.1%

Major complications: 5%

Complications of AF Ablation

Circulation. 2012;125:1439-1445



One of the most serious complications of AF ablation

The first case was reported in 2001.

Rare, but the incidence may be underestimated because of

under-reporting or misdiagnosis.

Gillinov AM et al. J Thorac Cardiovasc Surg. 2001;122:1239-40.


Catheter Ablation of AF in Korea

Annual case volume by year from 2001 to 2017

13 23 36 46199

321 383 408

643

959

1271

16351726

19112097

2530

3303

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

AF

Courtesy of Abbott Korea

AF

ab

latio

n c

ase

s u

sin

g 3

D m

ap

pin

g s

yste

m

Year


Characteristics of Patients with AE Fistula

5,721 patients undergoing 6,724 procedures from 3 centers in Korea

A total of 10 patients developed AE fistula (0.15% per procedure).

All occurred during first-time RFCA. Mean duration from RFCA: 23 days

Mortality rate: 80%

Kim YG, Shim J, Kim YH et al. J Cardiovasc Electrophysiol. 2018;29:1343–1351.


Ablation Lesion Sets of Patients

All patients underwent PVI.

Substrate modification

− 3 posteroinferior line ablation and 1 CFAE guided ablation at posterior wall



CT Images of AE Fistula


8 patients had AE-fistula near LIPV.

All patients had very close distance

between esophagus and LIPV.


Risk Factors of Atrioesophageal Fistula

Old age

Low body weight

High CHA2DS2-VASc score



64 year-old male, s/p liver transplantation

Endoscopic repair failed to heal

Management of AE Fistula


Management of AE Fistula

57 year-old male

Esophageal repair and simple LA suture reoperation


CASE ASN #2056945

58-year-old female, Palpitation and SOB

Diagnosed with PeAF and HF in 2015, refractory to AAD

CHA2DS2-VASc=2, LA=46.2 mm, EF=35%


CASE ASN #2056945

RFCA for AF (PVI + CFAE + CTI)


CASE ASN #2056945

Visited ER 23 days after RFCA due to fever and

myalgia blood pressure drop, confuse mentality

CT Scan, 23 days after RFCA


CASE ASN #2056945

Risk of cerebral embolism was very high.

But, operation room was not available.

VA-ECMO application and VF induction

Can reverse blood flow and prevent both air and septic embolism


CASE ASN #2056945

TTE after ECMO and VF Induction

Continuous regurgitant flow from aorta to LV


CASE ASN #2056945

Operation

• On-pump LA repair with bovine pericardial patch

• Esophageal primary repair with intercostal muscle flap

F/U CT Scan, POD #30


CASE ASN #2056945

Brain MRI, HD #11


CASE ASN #2056945

Endoscopy, POD #31


CASE ASN #2056945

Hospital course

− Discharged without neurologic symptoms 3 months after admission

− Free from AF

− Edoxaban, Sacubitril/valsartan, bisoprolol, and spironolactone


To Avoid Esophageal Injury

Imaging study before ablation (CT/MRI)

Esophageal mucosal protection

Esophageal temperature monitoring

Limiting energy delivery on the posterior wall

Mechanical deviation of the esophagus

Esophageal insulation from thermal injury


CF-Sensing Catheters and AE Fistula

Black-Maier E et al. Heart Rhythm. 2017;14(9):1328-1333.

Manufacturer and User Facility Device Experience (MAUDE) database

CF-sensing catheters was associated with increased rates of AE fistula

formation.

Possible explanation: one-size-fits all approach (FTI > 400 g/s)


Contents





LAA

I

aVF

V1

LAA potential (-)LAA LAA potential


Electrical isolation of LAA (EIA) can occur inadvertently or

intentionally during catheter ablation (CA) of AF.



BELIEF Randomized Trial: Effect of empirical LAA isolation on long-

term procedure outcome in patients with LPeAF

Di Biase et al. J Am Coll Cardiol. 2016;68(18):1929-1940.

N=85 N=88


CASE PDG #1870681

M/62, Redo RFCA (AT termination during LAA ablation)


CASE PDG #1870681

LAA isolation

LAA

I

aVF

V1

Dissociated potential

LAA


CASE PDG #1870681

LAA angiography

No LAA isolationLAA isolation (Pt)

RAO 30° RAO 30°


CASE PDG #1870681

F/U TEE

INR=1.15 (warfarin dose was reduced d/t gum bleeding)


While LAA electrical isolation might improve the clinical

success in AF ablation,

The thromboembolic risk of the isolated appendage is a

major concern.

LAA Isolation and Risk of Stroke



KUMC RFCA registry

• Between 1998.06 – 2016.05

• 2,352 first-time RFCA procedures

• 2,997 total procedures including repeat procedures

39 patients had LAA isolation during RFCA

• 11 LAA isolation events during first-time RFCA

• 28 LAA isolation events during repeat procedures

66 ischemic stroke or TIA events occurred

• 9 events occurred in patients with LAA isolation (23%)

• 57 events occurred in patients without LAA isolation (2.5%)



Kim YG, Shim J, Kim YH et al. Heart Rhythm. 2018;15:1746-53.

Baseline Characteristics


Effect of Late Recurrence on Stroke



Effect of LAA Isolation on LAA Flow Velocity



Contents





LAA Size and Risk of Stroke

Lee JM et al. Heart Rhythm. 2017;14:1297-1301

Larger LAA size and decreased emptying velocity was an independent

predictor of stroke


Anterior Line & Delayed Activation of LAA

V1

LAA

LAA

CSp

CSd

aVF

Delayed activation after QRS


Delayed activation of LAA results in simultaneous

contraction of LAA and LV.

This might predispose LAA to higher intraluminal

pressure and cause adverse hemodynamic effects.

Consequence of Delayed Activation of LAA


Changes in LA and LAA after RFCA: a Follow-up MRI Study


Changes in LA and LAA after RFCA: a Follow-up MRI Study

Kim YG, Shim J, Kim YH et al. Sci Rep. 2018;8(1):7871.

Patients Characteristics

N=123

Age (years) 55.1±10.6

Male sex, n (%) 99 (80.5)

Paroxysmal, n (%) 53 (43.1)

CHF, n (%) 5 (4.1)

Hypertension, n (%) 42 (34.1)

Diabetes, n (%) 10 (8.1)

Stroke/TIA, n (%) 12 (9.8)

Vascular disease, n (%) 4 (3.2)

CHA2DS2-VASc 1.2±1.3

Substrate modification, n (%) 46 (37.4)

Late recurrence, n (%) 78 (63.4)


Changes in LA and LAA Volume after RFCA

Before RFCA After RFCA

LA volume by MRI(cm3)


LAA volume by MRI(cm3)

99.5±38.4 vs. 74.6±28.5p < 0.001

19.4±8.5 vs. 23.7±13.3p < 0.001





LAA to LA

Ratio (%)

17.4±7.1 vs. 24.9±10.0

p < 0.001




No anterior line

block (n = 92)

Delayed LAA

activation (n = 31)

Mean SD Mean SD p value

Baseline LAV 97.6 42.3 113.7 45.2 0.108

F/U LAV 74.7 28.2 73.0 28.6 0.780

∆ LAV -20.8 23.9 -39.1 28.1 0.002

Baseline LAAV 19.9 7.3 18.0 11.3 0.380

F/U LAAV 23.5 8.5 24.2 22.4 0.873

∆ LAAV 3.7 5.6 6.2 12.8 0.127

Delayed Activation of LAA and Changes in LA & LAA





Relationship between change in SEC grade and ΔLA & ΔLAA volume


LAA Emptying on VENC-MRI


Normal Activationof LAA

The flux and timing of LAA emptying on VENC-MRI

Hwang SH, Shim J, Kim YH et al. Under review


Posterior wall of LA near left inferior pulmonary vein was

the most vulnerable location for AE fistula.

Risk factors for AE fistula were old age, low body weight,

and high CHA2DS2-VASc score.

Electrical isolation of LAA increases the risk of ischemic

stroke or TIA regardless of post-isolation flow velocity of

LAA.

Not only LAA isolation but also delayed activation of LAA

after ablation raise a concern about adverse hemodynamic

effect and thromboembolic events because of increase in

LAA volume and decrease in LAA emptying flow.

Conclusions

khrs 2019 june 21, 2019k-hrs.org/khrs/2019_2/serious complications of af... · 2019-07-04 · after...

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