[Late complications after atrial fibrillation ablation : Diagnosis and management]

Delayed complications may occur up to weeks after atrial fibrillation (AF) ablation and are usually a consequence of initial injury during ablation and ongoing processes progressing to severe symptomatic but late-onset events. A structured clinical follow-up of patients to appraise for late complications is therefore imperative for all centers performing AF ablations. Late complications should also be reported when testing new ablation technologies. Red flag symptoms like fever, neurological events, and syncope but also delayed onset thoracic pain, dyspnea, exercise intolerance or gastrointestinal symptoms within the first months after AF ablation should trigger standardized diagnostic testing to evaluate for complications like esophageal injury/esophagoatrial fistula, gastroparesis, pulmonary vein stenosis (can become symptomatic even later), diaphragmatic paralysis, or late pericarditis/pericardial effusion. Whereas severe late complications are rare, the remote onset of associated symptoms warrants a high degree of awareness of all medical disciplines involved in the follow-up and also on the patient side to assure appropriate management without further delay. Indicative symptoms, incidences, and standardized management workflows for late complications like esophagoatrial fistula, gastroparesis, pulmonary vein stenosis, phrenic nerve injury/diaphragmatic palsy, and late pericarditis/pericardial effusion are discussed. Different imaging modalities have been used to clarify diagnosis and clinical relevance of these complications. Treatment options may range from wait-and-watch to emergency surgical interventions.