First-Time Catheter Ablation for Atrial Fibrillation Safer Than Ever

For patients with symptomatic A-Fib, catheter ablation is a commonly performed procedure. However, it does have potential complications. As with any procedure, the informed patient needs to know the risk factors.

To determine the most recent complication rates, researchers did a systematic review and pooled analysis of 89 studies from the past 10 years. Their results were published in May 2023.

Research Methods 

EDLINE and EMBASE databases were searched from January 2013 to September 2022 for randomized control trials that included patients undergoing a first ablation procedure using either radiofrequency or cryoballoon.

A total of 89 studies met inclusion criteria. A total of 15,701 patients were included in the current analysis.

Survey Findings

Vascular complications (i.e., bleeding and clotting) were the most frequent type of complication (1.31%).

The next most common complications were pericardial effusion/tamponade (i.e., fluid buildup around the heart) (0.78%) and stroke/transient ischemic attack (blood clot to the brain) (0.17%).

During the 10-year period of the analysis, procedure-related complication rates were:
• Overall 4.51%
• Severe  2.44%

Comparing the earlier 5-year period to the most recent 5-year period, complication rates were:
• Earlier period: 5.31%
• Most recent period: 3.77%.

Over the 2 time periods, mortality rates were stable.

There was no significant difference as to pattern of A-Fib, ablation technique, or ablation strategies beyond the pulmonary vein isolation.

Researchers Conclusions

Procedure-related complications and mortality rates associated with A-Fib catheter ablation are low.

Complication rates have declined in the past decade (2013-2022).

A significant improvement in the safety of the procedure was observed over the last 5 years (2018-2022).

Neither the type of energy used for ablation nor the creation of additional lesions in addition to the pulmonary veins significantly influenced the procedural complication rate.

What This Means for A-Fib Patients

One of the drawbacks of these findings from a patient’s perspective it that it doesn’t differentiate between major and minor complications.

All Complications Are Not Equal: For example, vascular complications (such as bruising or bleeding at the catheter insertion points) are usually minor and easily taken care of with no lasting consequences.

More serious complications are:

• Tamponade: Blood can bleed into the pericardium sac that surrounds the heart compressing it. Most centers and Electrophysiologists (EPs) are well aware of this and can move swiftly to drain off the extra blood.

• Atrioesophageal Fistula: This is a very rare complication (less than 1 in 1000) but one which can kill you. When a catheter makes an RF burn (lesion) near the esophagus, the heat may damage the esophagus wall which can later be eroded by gastric acids allowing blood to leak into the esophagus. Most centers and EPs now take extensive precautions to prevent this. (The new technology, Pulse Field Ablation, virtually eliminates this complication, see Pulsed Field Ablation—Emerging Tech for Atrial Fibrillation)

• Stroke: During a catheter ablation you are on heavy-duty anticoagulants so strokes are rare (0.17%). But as with anyone with A-Fib, strokes can occur.

In this analysis of 89 studies the overall major complication rate was very small.

First-Time Catheter Ablation: The bottom line for us patients is that first-time catheter ablation (PVA) is one of the safest procedures you can have in a hospital. (FYI: By comparison, the complication rate for the common appendectomy is around 18%.)

In practice, for most A-Fib patients, the actual risks are so small that it’s safer getting a PVA than not getting one.

A PVA is safe and afterwards certainly feels a lot better than a life in A-Fib and/or a life on antiarrhythmic drugs and anticoagulants. One reason people get a PVA is so that they don’t have to live the rest of their lives on these drugs.

Catheter Ablation is Considered a Low-Risk Procedure: Over 1 million catheter ablations are performed annually in the U.S.

The complication rate has continued to decrease.  In this analysis a significant improvement in safety was observed over the last 5 years.

But Beware of Low-Volume Operators: As patients we need to be aware that complications come mostly from low volume operators (those who perform less than 25 ablations a year), and that 81% of all ablations are performed by low volume operators.

This is important! When choosing to have a catheter ablation, make the effort to find high volume operators and experienced hospitals.

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