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GENERAL CONSIDERATIONS During the past several de­ cades, electrophysiological (EP) studies have become well-­ established interventions not only for diagnostic and prognostic purposes but also as an effective therapeutic option for patients with arrhythmias. Like other invasive procedures, EP studies can have vari­ ous complications.As EP procedures are performed on an elective basis mainly on patients without life-­ threatening conditions, avoidance of iatrogenesis is of utmost importance. Therefore, preprocedural evaluation, proper patient preparation, and procedural planning are essential steps in preventing iatrogenesis . Patients who are at high risk of complications should be accurately identified and managed before an EP study. Complications related to EP studies may occur in ­ every step of patient preparation and throughout the procedure (from the beginning of sedation/anesthesia and obtaining vascular access ­ until removal of vascular sheaths; sometimes with a delay of weeks). A complication is defined as major if it results in permanent injury or death, requires corrective action, or prolongs hospitalization. Any other complication is defined as minor. RISK ­FACTORS Before any diagnostic or therapeutic EP procedure, a patient should be assessed for both patient-­ related risk ­ factors (e.g., valvular heart disease, heart failure, myo­ car­ dial ischemia, electrolyte abnormalities, frailty) and procedure-­ related risk ­ factors (e.g., ablation of parahisian accessory pathway, parahisian atrial tachycardia, atrioventricular nodal reentrant tachycardia [AVNRT], left-­ sided ablation, atrial fibrillation (AF), atrial flutter, ablation in coronary sinus). Patients with decompensated heart failure, ongoing ischemia, or severe cases of aortic stenosis, mitral stenosis, hypertrophic obstructive cardiomyopathy, or three-­ vessel coronary artery disease are especially at high risk, as induction of sustained tachycardia during the EP study may lead to severe hemodynamic deterioration. Any electrolyte abnormality or other reversible ­ causes of arrhythmias (such as hypo-­or hyperthyroidism ) should be treated, and patients with known allergies should be premedicated before the procedure. CHAPTER 22 Iatrogenic Aspects of Cardiac Electrophysiology Boris Rudic, Erol Tülümen, Volker Liebe, and Martin Borggrefe 256 / Iatrogenic Aspects of Cardiac Electrophysiology during 22% of ablation procedures in adults (5). The risks for development of ge­ ne­ tic defects and fatal malignancy from one hour of fluoroscopy was predicted to be 20 per 1 million births and 0.1%, respectively (2). The risk for a fatal malignancy resulting from radiation exposure is age dependent; in a child younger than 14 years of age, the risk was found to be about twice that for a 35-­ year-­ old (2). Secondary to a conventional EP procedure, the lifetime risk for all cancers mortality for a patient at age 15 years was estimated at 136 per 100,000 (male) and 186 per 100,000 (female); the lifetime risk for all cancers incidence for a patient at age 15 years was estimated at 321 per 100,000 (male) and 486 per 100,000 (female). At age 35 years, the lifetime risks ­ were reduced: for mortality, 94 per 100,000 (male) and 119 per 100,000 (female); for incidence, 201 per 100,000 (male) and 267 per 100,000 (female). Undergoing a conventional EP procedure at 35 years of age would result in almost one week of “life lost” and about two weeks of “life affected” per patient, according to the Biological Effects of Ionizing Radiation (BEIR) empirical risk models (6). Despite prolonged fluoroscopy durations, radiation exposure to patients and operators can be reduced with very low frame pulsed fluoroscopy (less than four per second), avoidance of magnification, posterior-­ anterior or low angulation projection, and optimal adjustment of fluoroscopy exposure rates. PROCEDURE-­SPECIFIC COMPLICATIONS Right-­Sided Endocardial Procedures EP studies with only right-­ sided access are generally accepted as safe, with very low complication rates and almost negligible mortality. Complications that may occur with right-­ sided procedures are vascular access–­ related complications (e.g., bleeding, hematoma, pseudoaneurysm, arteriovenous fistula, infection at vascular access site), systemic infection, deep venous thrombosis and thromboembolism (with or without pulmonary embolism), complete atrioventricular (AV) block, bundle branch block, pneumothorax, cardiac perforation and tamponade, myo­ car­ dial Specific risks associated with a planned EP procedure should be evaluated and, if needed, extra precautions should be taken to avoid complications (e.g., transesophageal echocardiography to exclude thrombus in left atrial appendage before pulmonary vein isolation; invasive hemodymanic monitoring; preapplied adhesive defibrillator pads). When complications do occur, they should be recognized promptly and corrective mea­ sures taken immediately. Considering both patient-­and procedure-­ related risk ­ factors, the attending physician should estimate the level of risk, potential complications, and pitfalls in the par­ tic­ u­ lar EP procedure...


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