In-Hospital Pulmonary Arterial Embolism after Catheter Ablation of Over 45,000 Cardiac Arrhythmias: Individualized Case Analysis of Multicentric Data

Abstract

Objective and Background Data on incidence of in-hospital pulmonary embolisms (PE) after catheter ablation (CA) are scarce. To gain further insights, we sought to provide new findings through case-based analyses of administrative data. Methods Incidences of PE after CA of supraventricular tachycardias (SVT), atrial fibrillation (AF), atrial flutter (AFlu), and ventricular tachycardias (VT) in three German tertiary centers between 2005 and 2020 were determined and coded by the G-DRG (German Diagnosis Related Groups System) and OPS (German Operation and Procedure Classification) systems. An administrative search was performed with a consecutive case-based analysis. Results Overall, 47,344 ablations were analyzed (10,037 SVT; 28,048 AF; 6,252 AFlu; 3,007 VT). PE occurred in 14 (0.03%) predominantly female (n = 9; 64.3%) patients with a mean age of 55.3 ± 16.9 years, body mass index 26.2 ± 5.1 kg/m2, and left ventricular ejection fraction of 56 ± 13.6%. PE incidences were 0.05% (n = 5) for SVT, 0.02% (n = 5) for AF, and 0.13% (n = 4) for VT ablations. No patient suffered PE after AFlu ablation. Five patients (35.7%) with PE after CA had no prior indication for oral anticoagulation (OAC). Preprocedural international normalized ratio in PE patients was 1.2 ± 0.5. Most patients with PE following CA presented with symptoms the day after the procedure (n = 9) after intraprocedural heparin application of 12,943.2 ± 5,415.5 IU. PE treatment included anticoagulation with either phenprocoumon (n = 5) or non-vitamin K-dependent OAC (n = 9). Two patients with PE died after VT/AF ablation, respectively. The remaining patients were discharged without sequels. Conclusion Over a 15-year period, incidence of PE after ablation is low, particularly low in patients with ablation for AF/AFlu. This is most likely due to stricter anticoagulation management in these patients compared with those receiving SVT/VT ablation procedures and could argue for continuation of OAC prior to ablation. Optimizing periprocedural anticoagulation management should be subject of further prospective trials.

Pulmonary Thromboembolism after Catheter Ablation of Cardiac Arrhythmias

“…3 In this issue of the Thrombosis and Haemostasis, Doldi et al reported the low incidence of CA-related PE (0.03%), analyzing more than 47,000 CA procedures for cardiac arrhythmias (i.e., supraventricular tachycardia [SVT], atrial flutter, atrial fibrillation [AF], and ventricular tachycardia) that were performed in three German tertiary centers over the 15-year period. 4 The patients who have suffered PE were predominantly female; however, there were no differences in other main clinical characteristics between those with and without PE. The authors reported fatal outcome in 2 out of 14 patients due to massive PE.…”

“…2 The present study from Germany confirmed these findings. 4 Again, the incidence of clinically inapparent PE after CA seems to be much higher than occurrence of manifest PE. For example, among 71 consecutive patients undergoing CA of AF, asymptomatic PE was demonstrated by routine computed tomography after ablation in 6 patients (8%).…”

“…16 Finally, while high power ablation with conventional RF catheters increases the risk of the catheter tip charring, denaturation of blood proteins, and thrombosis, the irrigated-tip catheter use decreases the likelihood of clot formation. 15 Since the PE incidence was lower after AF (0.02-0.29%%) than after SVT ablation (0.05-1.67%), 2,4 it seems that preprocedural anticoagulation may prevent postprocedure PE. However, although the anticoagulation strategy for AF (leftsided) ablation is well standardized, there is no consistent guidelines for routine anticoagulation in patients undergoing right-sided CA procedures.…”