Image Source: Heart Rhythm Society

Death that results from catheter ablation of atrial fibrillation occurs in one in1,000 patients, according to a study in the May 12 issue of the Journal of the American College of Cardiology.

Using a retrospective case series, Riccardo Cappato, MD, from the Arrhythmias and Electrophysiology (EP) Center at I.R.C.C.S. Policlinico San Donato in Milan, Italy, and colleagues collected data relevant to the incidence and cause of intra- and post-procedural death occurring in patients undergoing CA of AF between 1995 and 2006 from 162 of 546 identified centers worldwide.

The researchers found that 32 deaths (0.98 per 1,000 patients) occurred during 45,115 procedures in 32,569 patients. Causes of deaths included cardiac tamponade in eight patients (one later than 30 days), stroke in five patients (two later than 30 days), atrioesophageal fistula in five patients and massive pneumonia in two patients, they wrote.

Cappato and colleagues reported that MI, intractable torsades de pointes, septicemia, sudden respiratory arrest, extrapericardial pulmonary vein (PV) perforation, occlusion of both lateral PVs, hemothorax and anaphylaxis to be responsible for one death each, while asphyxia from tracheal compression secondary to subclavian hematoma, intracranial bleeding, acute respiratory distress syndrome, and esophageal perforation from an intraoperative transesophageal echocardiographic probe were causes of one late death each.

The authors noted that their study "may be of help in designing more appropriate and efficient EP settings for increasing current standards of procedural safety, planning start programs in EP centers with limited facilities or experience, delivering recommendations by regulatory authorities, and developing safer technologies."

In the accompany editorial, Bernard Belhassen, MD, from the cardiac EP laboratory and department of cardiology at Tel-Aviv Sourasky Medical Center, Sackler School of Medicine and Tel-Aviv University in Tel-Aviv, Israel, asked whether a mortality rate of approximately one in 1000 can be considered an "acceptable risk" for patients with AF. However, he added that the data are of "great clinical interest, and the authors should be congratulated for a contribution that will certainly raise awareness in the EP community of the state of contemporary AF ablation."

Belhassen said that decreasing the risk of one in 1,000 procedures should be "a priority for the physicians involved in these procedures...Given that cardiac tamponade is the most frequently observed complication of AF ablation and the main cause of procedure-related mortality, it is of paramount importance that the operators themselves have good experience in percutaneous pericardiocenthesis or have immediate access to another physician who has mastered these skills."

However, Belhassen noted that Cappato et al "did not provide information on the availability of surgical backup for the patients who died due to tamponade, precluding the possibility of further elaborating the role of such backup in a course lethal to the patient."

As a result of these findings, he said that the question of whether AF ablation procedures should only be performed in EP centers where surgical backup is available remains unresolved," adding that surgical backup is mandatory and that it may prevent a lethal outcome in some patients.