Complications of catheter ablation for atrial fibrillation and their prevention: review
https://doi.org/10.15829/1560-4071-2025-6728
EDN: RJZQCQ
Abstract
Interventional treatment of atrial fibrillation, one of the most common arrhythmias, involves various ablation techniques. Their potential has expanded in recent years due to the availability of electromagnetic fields (electroporation) in addition to thermal myocardial procedures (radiofrequency or cryoablation). Surgical treatment of any type is associated with a certain risk of various complications, some of which are more common with traditional techniques, while others are more common with newer ones. The range of possible complications and the extensive research on this topic require further study to better understand the problem and treat patients in clinical practice. This review presents the main types of potential complications associated with atrial fibrillation ablation and analyzes data from recent large studies.
About the Authors
S. V. NemtsovRussian Federation
Akkuratova str., 2, St. Petersburg, 197341
D. S. Lebedev
Russian Federation
Akkuratova str., 2, St. Petersburg, 197341
References
1. Van Gelder IC, Rienstra M, Bunting KV, et al.; ESC Scientific Document Group. 2024. ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3314- 414. doi:10.1093/eurheartj/ehae176. Erratum in: Eur Heart J. 2025;46(41):4349. doi:10.1093/eurheartj/ehaf306.
2. Arbelo E, Brugada J, Blomström-Lundqvist C, et al. Contemporary management of patients undergoing atrial fibrillation ablation: in-hospital and 1 year follow-up findings from the ESC-EHRA atrial fibrillation ablation long-term registry. Eur Heart J. 2017;38(17):1303-16. doi:10.1093/eurheartj/ehw564.
3. Benali K, Khairy P, Hammache N, et al. Procedure-Related Complications of Catheter Ablation for Atrial Fibrillation. J Am Coll Cardiol. 2023;81(21):2089-99. doi:10.1016/j.jacc.2023.03.418.
4. Sareena G, Mintz AriJ, Sanjum S, et al. Current Treatment Options for Femoral Pseudoaneurysms. Early detection, monitoring, and appropriate treatment for femoral pseudoaneurysms are important to reduce morbidity. Cardiac Interventions Today. 2023;17(4):55-9.
5. Waigand J, Uhlich F, Gross CM, et al. Percutaneous treatment of pseudoaneurysms and arteriovenous fistulas after invasive vascular procedures. Catheter Cardiovasc Interv. 1999;47(2):157-64. doi:10.1002/(SICI)1522-726X(199906)47:23.0.CO;2-Y.
6. Kirchhof P, Haeusler KG, Blank B, et al. Apixaban in patients at risk of stroke undergoing atrial fibrillation ablation. Eur Heart J. 2018;39(32):2942-55. doi:10.1093/eurheartj/ehy176.
7. Ströker E, de Asmundis C, Kupics K, et al. Value of ultrasound for access guidance and detection of subclinical vascular complications in the setting of atrial fibrillation cryoballoon ablation. Europace. 2019;21(3):434-9. doi:10.1093/europace/euy154.
8. Dong J, Vasamreddy CR, Jayam V, et al. Incidence and predictors of pulmonary vein stenosis following catheter ablation of atrial fibrillation using the anatomic pulmonary vein ablation approach: results from paired magnetic resonance imaging. J Cardiovasc Electrophysiol. 2005;16(8):845-52. doi:10.1111/j.1540-8167.2005.40680.x.
9. Taylor GW, Kay GN, Zheng X, et al. Pathological effects of extensive radiofrequency energy applications in the pulmonary veins in dogs. Circulation. 2000;101(14):1736-42. doi:10.1161/01.cir.101.14.1736.
10. Chugh A, Makkar A, Yen Ho S, et al. Manifestations of coronary arterial injury during catheter ablation of atrial fibrillation and related arrhythmias. Heart Rhythm. 2013;10(11):1638- 45. doi:10.1016/j.hrthm.2013.09.001.
11. Yamaji K, Fujihara K, Fukawa Y, et al. Sinus node dysfunction caused by a sinus node artery occlusion during catheter ablation and sinus rhythm restoration post-PCI. HeartRhythm Case Rep. 2024;10(12):886-9. doi:10.1016/j.hrcr.2024.08.022.
12. Kitamura T, Fukamizu S, Arai K, et al. Transient sinus node dysfunction following sinus node artery occlusion due to radiofrequency catheter ablation of the septal superior vena cava-right atrium junction. J Electrocardiol. 2016;49(1):18-22. doi:10.1016/j.jelectrocard.2015.11.001.
13. Takahashi Y, Jaïs P, Hocini M, et al. Acute occlusion of the left circumflex coronary artery during mitral isthmus linear ablation. J Cardiovasc Electrophysiol. 2005;16(10):1104-7. doi:10.1111/j.1540-8167.2005.50124.x.
14. European Heart Rhythm Association (EHRA); European Cardiac Arrhythmia Scoiety (ECAS); American College of Cardiology (ACC); American Heart Association (AHA); Society of Thoracic Surgeons (STS); Calkins H, Brugada J, Packer DL, et al. HRS/EHRA/ ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2007;4(6):816-61. doi:10.1016/j.hrthm.2007.04.005. Erratum in: Heart Rhythm. 2009;6(1):148.
15. Eckardt L, Doldi F, Anwar O, et al. Major in-hospital complications after catheter ablation of cardiac arrhythmias: individual case analysis of 43031 procedures. Europace. 2023;26(1):euad361. doi:10.1093/europace/euad361.
16. Friedman DJ, Pokorney SD, Ghanem A, et al. Predictors of Cardiac Perforation With Catheter Ablation of Atrial Fibrillation. JACC Clin Electrophysiol. 2020;6(6):636-45. doi:10.1016/j.jacep.2020.01.011.
17. Fukasawa K, Umetani K, Yano T, et al. Constrictive pericarditis following atrial fibrillation catheter ablation with cardiac tamponade. HeartRhythm Case Rep. 2021;7(12):836-9. doi:10.1016/j.hrcr.2021.09.007.
18. Sudo K, Shigeta T, Oda A, et al. Pulmonary Vein Perforation and Life-Threatening Hemoptysis During Cryoballoon Ablation for Persistent Atrial Fibrillation. JACC Case Rep 2022;4(7):418-23. doi:10.1016/j.jaccas.2021.11.026.
19. Grove R, Kranig W, Coppoolse R, et al. Demand for open heart surgery due to entrapment of a circular mapping catheter in the mitral valve in a patient undergoing atrial fibrillation ablation. Clin Res Cardiol. 2008;97(9):628-9. doi:10.1007/s00392-008-0677-2.
20. Kesek M, Englund A, Jensen SM, et al. Entrapment of circular mapping catheter in the mitral valve. Heart Rhythm. 2007;4(1):17-9. doi:10.1016/j.hrthm.2006.09.016.
21. Tavernier R, Duytschaever M, Taeymans Y. Fracture of a circular mapping catheter after entrapment in the mitral valve apparatus during segmental pulmonary vein isolation. Pacing Clin Electrophysiol. 2003;26(8):1774-5. doi:10.1046/j.1460-9592.2003.t01-1-00268.x.
22. Kim EJ, Gerstenfeld EP, Pellegrini CN. Use of Adenosine to Release an Entrapped Catheter During Ablation of Premature Ventricular Complexes. JACC Case Rep. 2021;3(4):610-3. doi:10.1016/j.jaccas.2021.02.011.
23. Yagishita A, Ayabe K, Sakama S, et al. A Novel Technique to Release a PentaRay Entrapped in a Mechanical Mitral Valve Using an Ablation Catheter. JACC Clin Electrophysiol. 2020;6(12):1597-8. doi:10.1016/j.jacep.2020.08.017.
24. Gibson DN, Di Biase L, Mohanty P, et al. Stiff left atrial syndrome after catheter ablation for atrial fibrillation: clinical characterization, prevalence, and predictors. Heart Rhythm. 2011;8(9):1364-71. doi:10.1016/j.hrthm.2011.02.026.
25. Moon I, Lee SY, Lee E, et al. Extensive left atrial ablation was associated with exacerbation of left atrial stiffness and dyspnea. J Cardiovasc Electrophysiol. 2019;30(12):2782-9. doi:10.1111/jce.14241.
26. Witt C, Powell B, Holmes D, et al. Recurrent dyspnea following multiple ablations for atrial fibrillation explained by the "stiff left atrial syndrome". Catheter Cardiovasc Interv. 2013;82(5):E747-9. doi:10.1002/ccd.24556.
27. Wong GR, Lau DH, Baillie TJ, et al. Novel use of sildenafil in the management of pulmonary hypertension due to post-catheter ablation ‘stiff left atrial syndrome’. Int J Cardiol. 2015;181:55-6. doi:10.1016/j.ijcard.2014.12.012.
28. Chen S, Chun KRJ, Tohoku S, et al. Esophageal Endoscopy After Catheter Ablation of Atrial Fibrillation Using Ablation-Index Guided High-Power: Frankfurt AI-HP ESO-I. JACC Clin Electrophysiol. 2020;6(10):1253-61. doi:10.1016/j.jacep.2020.05.022.
29. Kaneshiro T, Kamioka M, Hijioka N, et al. Characteristics of Esophageal Injury in Ablation of Atrial Fibrillation Using a High-Power Short-Duration Setting. Circ Arrhythm Electrophysiol. 2020;13(10):e008602. doi:10.1161/CIRCEP.120.008602.
30. Müller J, Berkovitz A, Halbfass P, et al. Acute oesophageal safety of high-power short duration with 50 W for atrial fibrillation ablation. Europace. 2022;24(6):928-37. doi:10.1093/europace/euab329.
31. Schoene K, Arya A, Grashoff F, et al. Oesophageal Probe Evaluation in Radiofrequency Ablation of Atrial Fibrillation (OPERA): results from a prospective randomized trial. Europace. 2020;22(10):1487-94. doi:10.1093/europace/euaa209.
32. Tilz RR, Schmidt V, Pürerfellner H, et al. A worldwide survey on incidence, management, and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: the POTTER-AF study. Eur Heart J. 2023;44(27):2458-69. doi:10.1093/eurheartj/ehad250.
33. Piccini JP, Braegelmann KM, Simma S, et al. Risk of atrioesophageal fistula with cryoballoon ablation of atrial fibrillation. Heart Rhythm O2. 2020;1(3):173-9. doi:10.1016/j.hroo.2020.05.007.
34. Andrade JG, Wells GA, Deyell MW, et al. EARLY-AF Investigators. Cryoablation or Drug Therapy for Initial Treatment of Atrial Fibrillation. N Engl J Med. 2021;384(4):305-15. doi:10.1056/NEJMoa2029980.
35. Mörtsell D, Arbelo E, Dagres N, et al. ESC-EHRA Atrial Fibrillation Ablation Long-Term Registry investigators. Cryoballoon vs. radiofrequency ablation for atrial fibrillation: a study of outcome and safety based on the ESC-EHRA atrial fibrillation ablation long-term registry and the Swedish catheter ablation registry. Europace. 2019;21(4):581-9. doi:10.1093/europace/euy239.
36. Packer DL, Kowal RC, Wheelan KR, et al. STOP AF Cryoablation Investigators. Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) pivotal trial. J Am Coll Cardiol. 2013;61(16):1713-23. doi:10.1016/j.jacc.2012.11.064.
37. Tokuda M, Yamashita S, Sato H, et al. Long-term course of phrenic nerve injury after cryoballoon ablation of atrial fibrillation. Sci Rep. 2021;11(1):6226. doi:10.1038/s41598-021-85618-3.
38. Heeger CH, Sohns C, Pott A, et al. Phrenic Nerve Injury During Cryoballoon-Based Pulmonary Vein Isolation: Results of the Worldwide YETI Registry. Circ Arrhythm Electrophysiol. 2022;15(1):e010516. doi:10.1161/CIRCEP.121.010516.
39. Mol D, Renskers L, Balt JC, et al. Netherlands Heart Registration Ablation Committee. Persistent phrenic nerve palsy after atrial fibrillation ablation: Follow-up data from The Netherlands Heart Registration. J Cardiovasc Electrophysiol. 2022;33(3):559-64. doi:10.1111/jce.15368.
40. Sacher F, Monahan KH, Thomas SP, et al. Phrenic nerve injury after atrial fibrillation catheter ablation: characterization and outcome in a multicenter study. J Am Coll Cardiol. 2006;47(12):2498-503. doi:10.1016/j.jacc.2006.02.050.
41. Miyazaki S, Hachiya H, Taniguchi H, et al. Prospective Evaluation of Bilateral Diaphragmatic Electromyograms During Cryoballoon Ablation of Atrial Fibrillation. J Cardiovasc Electrophysiol. 2015;26(6):622-8. doi:10.1111/jce.12671.
42. Marinelli A, Trachanas K, Corso M, et al. An alternative method for phrenic nerve monitoring during cryoballoon procedures. Heart Rhythm O2. 2025;6(6):739-44. doi:10.1016/j.hroo.2025.03.016.
43. Andrade JG, Khairy P, Guerra PG, et al. Efficacy and safety of cryoballoon ablation for atrial fibrillation: a systematic review of published studies. Heart Rhythm. 2011;8(9):1444-51. doi:10.1016/j.hrthm.2011.03.050.
44. Cleland JG, Daubert JC, Erdmann E, et al.; CARE-HF study Steering Committee and Investigators. The CARE-HF study (CArdiac REsynchronisation in Heart Failure study): rationale, design and end-points. Eur J Heart Fail. 2001;3(4):481-9. doi:10.1016/s1388-9842(01)00176-3.
45. Tsotsolis N, Tsirgogianni K, Kioumis I, et al. Pneumothorax as a complication of central venous catheter insertion. Ann Transl Med. 2015;3(3):40. doi:10.3978/j.issn.2305-5839.2015.02.11.
46. Makita T, Kuwahara T, Takahashi K, et al. Severe hemothorax complications during atrial fibrillation ablation: Lessons from two cases. HeartRhythm Case Rep. 2022;8(8):586-90. doi:10.1016/j.hrcr.2022.05.018.
47. Kusano K, Inoue K, Kanaoka K, et al. J‐AB registry investigators. The Japanese Catheter Ablation Registry (J-AB): Annual report in 2022. J Arrhythm. 2024;40(5):1053-8. doi:10.1002/joa3.13141.
48. Wu L, Narasimhan B, Ho KS, et al. Safety and complications of catheter ablation for atrial fibrillation: Predictors of complications from an updated analysis the National Inpatient Database. J Cardiovasc Electrophysiol. 2021;32(4):1024-34. doi:10.1111/jce.14979.
49. Zheng T, Kong Y, Wu L, et al. Silent cerebral lesions after catheter ablation for atrial fibrillation using cryoballoon, hotballoon, laserballoon and radiofrequency catheters: a Bayesian network meta-analysis. Front Cardiovasc Med. 2025;11:1510468. doi:10.3389/fcvm.2024.1510468.
50. Asbach S, Biermann J, Bode C, et al. Early Heparin Administration Reduces Risk for Left Atrial Thrombus Formation during Atrial Fibrillation Ablation Procedures. Cardiol Res Pract. 2011;2011:615087. doi:10.4061/2011/615087.
51. Briceno DF, Villablanca PA, Lupercio F, et al. Clinical Impact of Heparin Kinetics During Catheter Ablation of Atrial Fibrillation: Meta-Analysis and Meta-Regression. J Cardiovasc Electrophysiol. 2016;27(6):683-93. doi:10.1111/jce.12975.
52. Tyrak K, Batko J, Hołda J, et al. Association between the left-sided atrial septal pouch and the cryptogenic stroke — an updated systematic review and meta-analysis. Sci Rep. 2025;15(1):37432. doi:10.1038/s41598-025-21285-y.
53. Moser H, Go D, Lai E, et al. Left atrial septal pouch thrombus prior to catheter ablation for atrial fibrillation. JACC. 2023; 81. doi:10.1016/S0735-1097(23)04336-X.
54. Boga M, Suhai FI, Orbán G, et al. Incidence and predictors of stroke and silent cerebral embolism following very high-power short-duration atrial fibrillation ablation. Europace. 2023;25(11):euad327. doi:10.1093/europace/euad327.
55. Shah D, Dumonceau JM, Burri H, et al. Acute pyloric spasm and gastric hypomotility: an extracardiac adverse effect of percutaneous radiofrequency ablation for atrial fibrillation. J Am Coll Cardiol. 2005;46(2):327-30. doi:10.1016/j.jacc.2005.04.030.
56. Aksu T, Golcuk S, Guler TE, et al. Gastroparesis as a Complication of Atrial Fibrillation Ablation. Am J Cardiol. 2015;116(1):92-7. doi:10.1016/j.amjcard.2015.03.045.
57. Miyazaki S, Nakamura H, Taniguchi H, et al. Gastric hypomotility after second-generation cryoballoon ablation-Unrecognized silent nerve injury after cryoballoon ablation. Heart Rhythm. 2017;14(5):670-7. doi:10.1016/j.hrthm.2017.01.028.
58. Camilleri M, Atieh J. New Developments in Prokinetic Therapy for Gastric Motility Disorders. Front Pharmacol. 2021;12:711500. doi:10.3389/fphar.2021.711500.
59. Field J, Wasilewski M, Bhuta R, et al. Effect of Chronic Domperidone Use on QT Interval: A Large Single Center Study. J Clin Gastroenterol. 2019;53(9):648-52. doi:10.1097/MCG.0000000000001183.
60. Janssens J, Peeters TL, Vantrappen G, et al. Improvement of gastric emptying in diabetic gastroparesis by erythromycin. Preliminary studies. N Engl J Med. 1990;322(15):1028- 31. doi:10.1056/NEJM199004123221502.
61. Zheng T, Camilleri M. Management of Gastroparesis. Gastroenterol Hepatol (N Y). 2021;17(11):515-25.
62. Chéhirlian L, Koutbi L, Mancini J, et al. High incidence of phrenic nerve injury in patients undergoing pulsed field ablation for atrial fibrillation. Heart Rhythm. 2025;22(12):e1206 e1213. doi:10.1016/j.hrthm.2025.08.010.
63. Nies M, Koruth JS, Mlček M, et al. Is the esophagus spared during pulsed field ablation? Early histopathology and in vivo esophageal retraction. Heart Rhythm. 2025; S1547- 5271(25)02612-8. doi:10.1016/j.hrthm.2025.06.033.
64. Higuchi S, Im SI, Stillson C, et al. Gerstenfeld EP. Effect of Epicardial Pulsed Field Ablation Directly on Coronary Arteries. JACC Clin Electrophysiol. 2022;8(12):1486-96. doi:10.1016/j.jacep.2022.09.003.
65. Tam MTK, Chan JYS, Chan CP, et al. Effect of Pulsed-Field Ablation on Human Coronary Arteries: A Longitudinal Study With Intracoronary Imaging. JACC Clin Electrophysiol. 2025;11(7):1478-88. doi:10.1016/j.jacep.2025.03.014.
66. Cho MS, Lee SR, Black-Maier E, et al. Complications associated with pulsed field ablation vs radiofrequency catheter ablation of atrial fibrillation. Heart Rhythm. 2025;22(9):2194- 200. doi:10.1016/j.hrthm.2024.10.063.
67. Miyazaki S, Kobori A, Sasaki Y, et al. Real-World Safety Profile of Atrial Fibrillation Ablation Using a Second-Generation Cryoballoon in Japan: Insight From a Large Multicenter Observational Study. JACC Clin Electrophysiol. 2021;7(5):604-13. doi:10.1016/j.jacep.2020.11.016.
68. Nakamura T, Takami M, Fukuzawa K, et al. Incidence and Characteristics of Coronary Artery Spasms Related to Atrial Fibrillation Ablation Procedures — Large-Scale Multicenter Analysis. Circ J. 2021;85(3):264-71. doi:10.1253/circj.CJ-20-1096.
69. Ekanem E, Neuzil P, Reichlin T, et al. Safety of pulsed field ablation in more than 17,000 patients with atrial fibrillation in the MANIFEST 17K study. Nat Med. 2024;30(7):2020-9. doi:10.1038/s41591-024-03114-3.
70. Reddy VY, Petru J, Funasako M, et al. Coronary Arterial Spasm During Pulsed Field Ablation to Treat Atrial Fibrillation. Circulation. 2022;146(24):1808-19. doi:10.1161/CIRCULATIONAHA.122.061497.
71. Sowers AE, Lieber MR. Electropore diameters, lifetimes, numbers, and locations in individual erythrocyte ghosts. FEBS Lett. 1986;205(2):179-84. doi:10.1016/0014-5793(86)80893-6.
72. Peng W, Yue Y, Zhang Y, et al. Scheduled dosage regimen by irreversible electroporation of loaded erythrocytes for cancer treatment. APL Bioeng. 2023;7(4):046102. doi:10.1063/5.0174353.
73. Popa MA, Venier S, Menè R, et al. Characterization and Clinical Significance of Hemolysis After Pulsed Field Ablation for Atrial Fibrillation: Results of a Multicenter Analysis. Circ Arrhythm Electrophysiol. 2024;17(10):e012732. doi:10.1161/CIRCEP.124.012732.
74. Gupta A, Perera T, Ganesan A, et al. Complications of catheter ablation of atrial fibrillation: a systematic review. Circ Arrhythm Electrophysiol. 2013;6(6):1082-8. doi:10.1161/CIRCEP.113.000768.
75. Providência R, Adragão P, de Asmundis C, et al. Impact of Body Mass Index on the Outcomes of Catheter Ablation of Atrial Fibrillation: A European Observational Multicenter Study. J Am Heart Assoc. 2019;8(20):e012253. doi:10.1161/JAHA.119.012253.
76. Ekanem E, Reddy VY, Schmidt B, et al. MANIFEST-PF Cooperative. Multi-national survey on the methods, efficacy, and safety on the post-approval clinical use of pulsed field ablation (MANIFEST-PF). Europace. 2022;24(8):1256-66. doi:10.1093/europace/euac050. Erratum in: Europace. 2023;25(2):449. doi:10.1093/europace/euac250.
77. Schmidt B, Bordignon S, Neven K, et al. EUropean real-world outcomes with Pulsed field ablatiOn in patients with symptomatic atRIAl fibrillation: lessons from the multicentre EU-PORIA registry. Europace. 2023;25(7):euad185. doi:10.1093/europace/euad185.
78. Jäckel M, Kaier K, Steinfurt J, et al. In-hospital safety of cryoballoon and radiofrequency ablation in patients with atrial fibrillation-German nationwide analysis of more than 300,000 procedures. Heart Rhythm. 2025;22(12):3131-9. doi:10.1016/j.hrthm.2025.02.024.
79. Kattel S, Tan Z, Lin Z, et al. Procedural volume and outcomes with atrial fibrillation ablation: A report from the NCDR AFib Ablation Registry. Heart Rhythm. 2025;22(1):37-48. doi:10.1016/j.hrthm.2024.06.056.
Review
For citations:
Nemtsov S.V., Lebedev D.S. Complications of catheter ablation for atrial fibrillation and their prevention: review. Russian Journal of Cardiology. 2025;30(4S):6728. (In Russ.) https://doi.org/10.15829/1560-4071-2025-6728. EDN: RJZQCQ
JATS XML








































