p.89 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e89

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

Table 26.  Complications After AF Catheter Ablation

Complication Frequency of Complication1–4 Timing of Complication Signs and Symptoms Diagnosis Treatment LA-esophageal fistula 0.2% 1-4 wk Chest pain, pain with swallowing, fever, stroke symptoms CT scan of chest Surgery Cardiac perforation with tamponade 0.4%-1.5% During procedure Hypotension Echocardiography Pericardiocentesis CVA/TIA 0.1%-1.0% During procedure and up to 1 wk Neurological findings MRI or CT scan Anticoagulate when safe PV stenosis 0.1%-0.8% Months Dyspnea, hemoptysis MRI or CT scan Stent Phrenic nerve paralysis 0.2%-0.4% During procedure Dyspnea Fluoroscopy Time Vascular access complications 1%-7% During procedure and up to 1 mo Pain, swelling at access site Ultrasound or CT scan Observation Vascular access complications requiring surgery 0.1%-0.3% During procedure and up to 1 mo Pain and swelling at access site Ultrasound or CT scan Surgery Death 0.1%-0.4% During procedure Pneumonia 0.4%-1.0% Days Cough, fever Chest x-ray Antibiotics AF indicates atrial fibrillation; CT, computed tomography; CVA, cerebrovascular accident; LA, left atrial; PV, pulmonary vein; TIA, transient ischemic attack; and MRI, magnetic resonance imaging.

increased in patients with a CHA2DS2-VASc score ≥2 who discontinued oral anticoagulation after 3 months (HR, 2.48 [95% CI, 1.11-5.52]; P<0.05).21 In this same study, no increased risk was observed that was associated with discontinuation after 3 months in those with a CHA2DS2-VASc score of 0 to 1. Ongoing randomized trials are investigating whether oral anticoagulation can be safely discontinued in patients who have no significant arrhythmia recurrences after catheter ablation. Finally, the OPTION (Comparison of Anticoagulation With Left Atrial Appendage Closure After AF Ablation) trial (NCT03795298) will test whether LAAO is noninferior to continued oral anticoagulation after catheter ablation of AF.22 Given (1) the absence of randomized data that directly address this question, (2) the absence of consistent data demonstrating a lower risk of stroke after ablation, and (3) increased rates of stroke among persons with a CHA2DS2-VASc score ≥2 who discontinue oral anticoagulation after 3 months, persons who have undergone catheter ablation AF should continue guideline-directed oral anticoagulation beyond 3 months based on their stroke risk, such as those with moderate-high risk of stroke. 8.4.5. Complications After AF Catheter Ablation Complications of AF catheter ablation occur in approximately 5% of patients, with most being vascular (Table 26).1–4 However, several life-threatening complications may occur. Complications are more common with annual operator procedures <25 patients and hospital procedures <50 patients.1 Some studies demonstrate a higher incidence of complications in wom- en,1 but the CABANA RCT did not.5 The most severe complication is an LA to esophageal fistula, which is often fatal but quite rare. Another life-threatening complication is pericardial tamponade, but this can usually be treated with prompt pericardiocentesis. Clinically significant strokes and TIAs are observed in <1% of patients.1–4 Deaths during ablations are typically from tamponade but may occur with strokes.1–4

Phrenic and vagal nerve paralysis are seen with cryoablation but are less common in radiofrequency ablation.2 Early reports of PV stenosis were largely due to ablation inside the veins; with antral ablation this is rarely seen. The most common complications include bruising and bleeding at the vascular access site. Less common vascular complications include damage to the arterial or venous system or an atrioventricular fistula requiring surgery.

8.5 Role of Pacemakers and ICDs for the

Prevention and Treatment of AF Recommendations for the Role of Pacemakers and ICDs for the Prevention and Treatment of AF Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 A 1 In patients with bradycardia requiring cardiac-

implanted electronic devices who have normal atrioventricular conduction, device selection and programming strategies to maintain atrioventricular synchrony and minimize ventricular pacing should be used to reduce the incidence and progression of AF. 1–6

2b B-NR 2 In selected patients with a pacemaker and

symptomatic atrial tachyarrhythmias, antitachycardia atrial pacing and ventricular pacing minimization may be useful for reducing symptoms.7–13

(Continued )

Downloaded from http://ahajournals.org by on October 7, 2026