Complications
Estimates depend on surgical or 'cut and sew' maze operation (rarely performed today) or surgically performed radiofrequency ablation. The newer energy-based surgical approaches to ablation such as radiofrequency ablation have a very low complication rate.
The risk of bleeding varies according to type of anticoagulant and patient risk factors. The definition of major and minor bleeding is not standard across studies, and the reported incidence of bleeding in the literature varies.
In cases of major bleeding, idarucizumab is approved for reversal of anticoagulant effects of dabigatran; it binds specifically to dabigatran preventing it from inactivating thrombin. Recombinant coagulation factor Xa (andexanet alfa) is approved for the reversal of the anticoagulant effects of the factor Xa inhibitors apixaban and rivaroxaban. For patients receiving warfarin, treatment with four-factor prothrombin complex concentrate (if available) in addition to intravenous vitamin K is recommended.[1][2]
Acute toxicity presents as acute respiratory distress syndrome within hours of administration. Long-term toxicity causes inflammation and/or fibrosis. Symptoms of an unexplained cough or dyspnoea should raise the question. A chest x-ray and pulmonary function tests (PFTs) with diffusion capacity are recommended. PFTs should be considered as follow-up when using the drug every 6 to 12 months. Will require discontinuation of the drug in most cases.
AF is an independent risk factor for death. The relative risk for death ranges from 1.3 to 2.6 and is increased in female patients.[193][194] Both AFFIRM and RACE trials demonstrated similar survival rate between the rate control group and the rhythm control group.[195][196] In the AFFIRM trial, mortality at 5 years was 21.3% versus 23.8%, respectively. The tendency towards higher mortality in the rhythm control group is explained by increased use of anti-arrhythmic drugs and under-representation of younger patients with normal hearts in these trials. In fact, a controlled trial suggests that restoring sinus rhythm with ablative therapy improves survival and quality of life compared with medical therapy of AF.[197] In a 600-day follow-up, 6% (38) of ablated patients and 16% (83) in the medical group had died.[197]
As shown in a substudy of the AFFIRM trial (a comparison of rate control and rhythm control in patients with AF), a recent history of smoking among patients with AF was associated with an increased risk of all-cause mortality. The results did not show any association with all-cause hospitalisation.[198]
Can occur due to profound effects on the atrioventricular node while in AF or due to the effects on the sinus node when in sinus rhythm, particularly in patients with underlying sinus node dysfunction. Can occur with anti-arrhythmic drugs (e.g., flecainide or amiodarone) as well. May require changing drug, or permanent pacing.
In patients with non-valvular AF, the annual adjusted stroke rate is 1.9% to 18.2% per year depending on patients' comorbidities and CHADS scores.[199] Overall, patients with AF have a fivefold increased risk of stroke.[3] Patients with AF and a history of stroke/transient ischaemic attack may be more likely to have subsequent ischaemic and haemorrhagic events than those without previous stroke/transient ischaemic attack.[200] Additionally, those who have an ischaemic stroke while receiving oral anticoagulation are at increased risk of recurrent ischaemic stroke and death.[201]
Strokes in people with AF are often severe, recurrent, and associated with permanent disability and high numbers of deaths.[3]
Preventing stroke, especially in older patients, is a vital health concern.[202][203][204] The challenge of prevention with either anticoagulants or antiplatelet agents lies with balancing reduction of risk of major stroke with the increased risk of bleeding, particularly intracranial bleeding.[100]
One cohort study concluded that patients with resolved AF remain at higher risk of stroke or transient ischaemic attack than patients without AF and that the risk is increased even in those in whom recurrent AF is not documented.[205]
Secondary to the vasodilatory effects of beta-blockers and calcium-channel blockers, as well as atrioventricular (AV) nodal effects slowing the heart rate. If this occurs, lowering the dose can be considered. Other causes of hypotension should be sought. If the strategy was rate control only, AV nodal ablation can be considered for rate control if drugs cause too many adverse effects. Rhythm control can also be reconsidered in some patients.
May be due to the negative inotropic effects of beta-blockers and calcium-channel blockers, as well as some anti-arrhythmic drugs. These drugs should be used cautiously in patients with poor left ventricular function and not at all in patients with overt clinical heart failure until the heart failure is treated and compensated. This can be challenging and there is a need to optimise the heart failure regimen.
May take many forms depending on the type and drug used. The most dangerous are ventricular arrhythmias such as ventricular tachycardia or torsades de pointes. Occurs with anti-arrhythmic drugs that prolong the QT or with drugs that prolong conduction such as propafenone in patients with underlying coronary disease. Physicians should know the pharmacology and drug interactions and use the recommendations outlined in the guidelines for the treatment of AF.
An unusual complication of amiodarone due to it containing iodine. Common to see elevated thyroid-stimulating hormone and more common to see hypothyroidism rather than hyperthyroidism unless the patient has a predilection to hyperthyroidism or a previous goitre. Can replace thyroid hormone orally for hypothyroidism but usual need to discontinue the drug if hyperthyroid and treat the symptoms of hyperthyroidism.
Complications vary with the technique and experience, and some have decreased with modification of ablation strategies. They include cerebrovascular events (0% to 4%), pulmonary vein stenosis (1% to 3%), oesophageal injury and fistula (about 0.01%, but probably underestimated), pericardial effusion (usually uncomplicated) (25%), pericardial tamponade (1%), organised atrial tachyarrhythmias (2% to 20%), and other rare complications such as aortic root injury and phrenic nerve injury.[206][207] Most of the complications are handled acutely. Pulmonary vein stenosis, although becoming less common with newer techniques, still remains a potential complication. Can present late with dyspnoea. Work-up should include computed tomography of pulmonary veins and ventilation perfusion scan. Treatment includes pulmonary vein stenting, but results are mixed. Best treatment is prevention with good technique.
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