European Heart Rhythm Association survey on the perceived severity of complications in atrial fibrillation ablation: development of a standardized scoring model

Aims: Atrial fibrillation (AF) ablation is associated with complications. These are sometimes categorized as mild or severe based on unspecified criteria. We conducted a survey of European electrophysiologists (EPs) to rank the perceived complication severity. Methods and results: A physician-based survey was conducted by the Scientific Initiative Committee of the European Heart Rhythm Association (EHRA). An online questionnaire was created asking EPs to score a list of complications on a scale from 0 (no complication) to 100 (procedural death). Three hundred respondents participated in the survey; however, 105 were excluded due to incomplete responses. Unexplained periprocedural death (90, interquartile range 50-100), atrio-oesophageal fistula (AEF 92, 80-100), procedural stroke (80, 59-89), and tamponade requiring surgery (70, 80-83) were the complications associated with highest scores. Among the intermediate complications, phrenic nerve palsy at discharge (49, 25-67) was ranked similarly to tamponade treated with pericardial puncture (50, 25-70) or periprocedural transient ischaemic attack (50, 25-70). Institutional infrastructural features such as cardiac surgery or stroke units had no impact on the scoring. Most respondents (89%) have experienced cardiac tamponade, procedural stroke (53%), and AEF (25%). When applied retrospectively to existing studies, the proposed EHRA AF ablation safety score demonstrated a trend towards improved AF ablation safety over time. Conclusion: The EHRA complication severity score provides a standardized, quantitative ranking of AF ablation complications, identifying periprocedural death and AEF as the most severe events. Based on the findings, we propose a novel EHRA AF ablation safety score that may contribute to a more objective safety comparison of AF ablation trials.