Rare complications in electrophysiological procedures

Catheter-based electrophysiological procedures are highly effective and generally considered safe. Although common complications are well described and managed according to standardized protocols, rare complications remain incompletely characterized despite their potential for severe morbidity and mortality. This review provides an overview of rare yet clinically relevant complications following electrophysiological ablation procedures, focusing on clinical presentation, diagnostic challenges, and principles of management and prevention. Rare complications are defined as those with a low incidence or those predominantly reported in case reports and small series, despite their clinical impact. The spectrum includes myocardial, valvular, vascular, and coronary injuries associated with radiofrequency and pulsed-field ablation; extracardiac and access-related bleeding; pulmonary and pleural complications; esophageal and left atrial injuries; as well as thromboembolic and hematological events. Emphasis is placed on atypical or delayed symptom presentation and the resulting diagnostic pitfalls. A mechanistic classification is proposed to support early recognition, targeted diagnostic work-up, and timely intervention. Increased clinical awareness, early use of advanced imaging, and interdisciplinary management are essential to improve patient outcomes. Systematic reporting and large-scale registries are crucial to better define incidence, risk factors, and long-term implications, particularly in the context of emerging ablation technologies.