Early mortality ‘a very real complication’ after catheter ablation of AFib

A study of patients undergoing catheter ablation of atrial fibrillation between 2010 and 2015 found that early post-ablation mortality rates increased over the half-decade, reaching 1.35% per quarter by the end of the research period.

The study, spearheaded by Weill Cornell Medicine-New York Presbyterian Hospital’s Edward P. Cheng, MD, PhD, and published in the Journal of the American College of Cardiology, examined 60,203 adults undergoing ablation for AFib between 2005 and 2010. Though catheter ablation of AFib has been around for two decades and is widely accepted as effective and safe, some recent work has suggested otherwise.

Right now, AFib ablation-related in-hospital death rates during index admissions hover between 0% and 0.8%. But Cheng and co-authors said most of the research backing those numbers relied on regional databases, single-payer databases, academic centers and national databases limited to information about index admissions. The team hypothesized mortality rates would be higher during early readmissions, which haven’t been considered.

“Recent studies have suggested an increasing trend in AFib ablation-related complication rates despite advances in catheter technology and operator experience,” Cheng et al. wrote in JACC. “As the overall volume of AFib ablation procedures performed worldwide continues to grow, an understanding of the real-world rates of serious complications is needed.”

The team drew from the all-payer, nationally representative Nationwide Readmissions Database for information on their study population. They defined early mortality as death during index admission for catheter ablation or death during 30-day readmission. Around 0.46% of cases—276 patients—met that primary endpoint, with more than half (54%) of deaths occurring during readmissions.

Between 2010 and 2015, quarterly rates of early mortality post-ablation rose, from 0.25% to 1.35%. Average time from ablation to death was around 12 days, and after adjustment for age and comorbidities the following factors were associated with a higher likelihood of death:

  • Procedural complications (4.1-fold increased risk of mortality)
  • Congestive heart failure (2.2-fold increased risk)
  • Low AFib ablation hospital volume (2.4-fold increased risk)
  • Complications due to cardiac perforation (3-fold increased risk)
  • Other cardiac complications (12.8-fold increased risk)
  • Neurologic etiologies (8.7-fold increased risk)

“When I first read this paper, my initial reaction was that the findings must be incorrect,” Hugh Calkins, MD, of Johns Hopkins Hospital in Baltimore, wrote in a related JACC editorial. “I have performed thousands of AFib ablation procedures over the past two decades, and I have never had a patient die as a result of the procedure. Furthermore, the landmark ablation trials that form the underpinning for the field of AFib ablation—such as FIRE AND ICE, CASTLE AF and CABANA—report no deaths.”

But, just as Cheng et al. pointed out, Calkins said, those studies were based on high-volume operators who often performed their procedures at academic centers. Calkins emphasized the fact that experience clearly matters when it comes to AFib ablation, since the best outcomes are consistently found at the highest-volume hospitals with the highest-volume operators.

“At the end of the day, this is a very important study that should serve as a wake-up call to all electrophysiologists who perform AFib ablation, all cardiologists who refer patients for this procedure, and all patients who are considering undergoing AFib ablation,” he wrote. “What is clear is that AFib ablation is not a benign procedure, and mortality is a very real complication.”