PACES/HRS expert consensus statement on the use of catheter ablation in children and patients with congenital heart disease: Developed in partnership with the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American Academy of Pediatrics (AAP), the American Heart Association (AHA), and the Association for European Pediatric and Congenital Cardiology (AEPC).

In 2002, an expert consensus statement was published on catheter ablation in children and adults with congenital heart disease (CHD), based on a conference held at the North American Society of Pacing and Electrophysiology in the year 2000.1Friedman R.A. Walsh E.P. Silka M.J. Calkins H. Stevenson W.G. Rhodes L.A. Deal B.J. Wolff G.S. Demaso D.R. Hanisch D. Van Hare G.F. NASPE expert consensus conference: Radiofrequency catheter ablation in children with and without congenital heart disease. Report of the writing committee. North American Society of Pacing and Electrophysiology.Pacing Clin Electrophysiol. 2002; 25: 1000-1017Crossref PubMed Google Scholar Since publication in 2002, numerous technological improvements have been introduced, including catheter cryoablation, 3-dimensional (3D) mapping, percutaneous epicardial ablation, and high-powered ablation catheters using passive or active tip cooling. In addition, the uses of catheter ablation in pediatrics have expanded to include the management of virtually every arrhythmia, including atrial fibrillation (AF). The Pediatric and Congenital Electrophysiology Society (PACES), in conjunction with the Heart Rhythm Society (HRS), has recently published related consensus guidelines and documents that include the following: the uses of catheter ablation for the management of asymptomatic Wolff-Parkinson-White (WPW) pattern found on the ECG (2012)2Cohen M.I. Triedman J.K. Cannon B.C. Davis A.M. Drago F. Janousek J. Klein G.J. Law I.H. Morady F.J. Paul T. Perry J.C. Sanatani S. Tanel R.E. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern.Heart Rhythm. 2012; 9: 1006-1024Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar; adult patients with congenital heart disease (2014)3Khairy P. Van Hare G.F. Balaji S. Berul C.I. Cecchin F. Cohen M.I. Daniels C.J. Deal B.J. Dearani J.A. Groot N. Dubin A.M. Harris L. Janousek J. Kanter R.J. Karpawich P.P. Perry J.C. Seslar S.P. Shah M.J. Silka M.J. Triedman J.K. Walsh E.P. Warnes C.A. PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD).Heart Rhythm. 2014; 11: e102-e165Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar; and ventricular arrhythmias in children with a structurally normal heart (2014).4Crosson J.E. Callans D.J. Bradley D.J. Dubin A. Epstein M. Etheridge S. Papez A. Phillips J.R. Rhodes L.A. Saul P. Stephenson E. Stevenson W. Zimmerman F. PACES/HRS expert consensus statement on the evaluation and management of ventricular arrhythmias in the child with a structurally normal heart.Heart Rhythm. 2014; 11: e55-e78Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar This consensus statement provides up-to-date clinical practice guidelines for the use of catheter ablation in children 0–18 years of age with any arrhythmia, and in all patients with congenital heart disease. This statement attempts to also be consistent, where possible, with the 2012 and 2014 documents noted above. In case of conflict, the more recent publication of this document would indicate it supersedes the prior recommendations. As with the 2012 and 2014 documents, the writing group for this document was formed by PACES in conjunction with HRS. The goal of the writing committee was to focus primarily on the methodology, utility, and safety of catheter ablation in various clinical settings, and not on the overall management of particular arrhythmias. By necessity, some aspects of management are included, particularly when incorporating the history of symptoms and treatments that might lead to a choice of ablation versus other therapeutic options. In general, the guidelines assume that the specific arrhythmia diagnosis will be identified before the final decision for ablation takes place; the document does not typically specify what testing is or should be performed to obtain the diagnosis. The consensus committee has reviewed and ranked the evidence, and has made recommendations based on the standard process described in a 2014 summary document on the ACC/AHA Practice Guidelines,5Jacobs A.K. Anderson J.L. Halperin J.L. Albert N.M. Bozkurt B. Brindis R.G. Curtis L.H. DeMets D. Fleisher L.A. Gidding S. Hochman J.S. Kovacs R.J. Ohman E.M. Pressler S.J. Sellke F.W. Shen W.K. Wijeysundera D.N. The evolution and future of ACC/AHA clinical practice guidelines: a 30–year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: 1208-1217Crossref PubMed Scopus (0) Google Scholar which are summarized here in Table 1. This statement is directed to all health care professionals who treat pediatric patients or who treat those with congenital heart disease and arrhythmias.Table 1Classification of recommendations and levels of evidence5Jacobs A.K. Anderson J.L. Halperin J.L. Albert N.M. Bozkurt B. Brindis R.G. Curtis L.H. DeMets D. Fleisher L.A. Gidding S. Hochman J.S. Kovacs R.J. Ohman E.M. Pressler S.J. Sellke F.W. Shen W.K. Wijeysundera D.N. The evolution and future of ACC/AHA clinical practice guidelines: a 30–year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: 1208-1217Crossref PubMed Scopus (0) Google ScholarClassification of Recommendations Class IConditions for which there is evidence and/or general agreement that a given procedure or treatment plan is beneficial, useful, and effective.Class IIConditions for which there is conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a procedure or treatment.Class IIaWeight of evidence/opinion is in favor of usefulness/efficacyClass IIbUsefulness/efficacy is less well established by evidence/opinion Class IIIConditions for which there is conflicting evidence and/or general agreement that a procedure or treatment is not useful/effective and in some cases might be harmfulLevels of EvidenceLevel of evidence AData derived from multiple randomized clinical trials or meta-analysesLevel of evidence BData derived from a single randomized trial or nonrandomized studies Level of evidence CObservational/registry studies or meta-analyses, or mechanistic studies on humans Level of evidence EConsensus opinion of experts, case studies, or standard of care Open table in a new tab For the purposes of this document, we have attempted to divide the recommendations into three categories: Safety—those related to general issues, such as substrate location, the risk of AV block, and coronary risk; Procedure—issues related to laboratory equipment, personnel, fluoroscopy use, ablation energy, catheter choice, sedation/anesthesia, and pre- and post-ablation procedure management; and Arrhythmia—issues related to the specific condition being managed. If the recommended guidelines are the same or largely overlapping for particular tachyarrhythmias, such as for atrioventricular (AV) node reentry tachycardia (AVNRT) and AV reentry tachycardia in the absence of pre-excitation (AVRT), the guidelines might be combined with specific references to the safety or procedure sections for issues involving items such as location or energy choice. The 2002 consensus document had multiple recommendations that depended on patient age, typically expressed as “>4 years” or “<5 years”. This committee reviewed the available evidence related to patient age and weight, which is detailed below (see Section 3.2), and provided its own expert opinions. The committee concluded that, in general, age was a less important factor than patient weight in determining the risk to benefit ratio for ablation. The committee chose a cutoff of “approximately 15 kg” to be used for multiple ablation indications, recognizing that a precise cutoff for weight or age should not be specified to cover every circumstance. The neonate or very small infant is the one exception, for whom age is also taken into account in some circumstances. The 24 members of the writing committee were selected for their expertise within their fields by PACES and/or HRS, and include 19 pediatric electrophysiologists, two adult electrophysiologists, two anesthesiologists, and an electrophysiology nurse practitioner. Because the evidence for the management of many pediatric arrhythmias is frequently limited to retrospective series or prospective adult series, the committee members were asked to consider the available evidence and their own approaches to patient management when deriving their expert opinions and suggested recommendations. Recommendations were then considered by the entire group. For the purposes of this document, “consensus” was defined as a 75% or greater agreement by the writing members, as was defined for the recently published ventricular arrhythmia consensus document.4Crosson J.E. Callans D.J. Bradley D.J. Dubin A. Epstein M. Etheridge S. Papez A. Phillips J.R. Rhodes L.A. Saul P. Stephenson E. Stevenson W. Zimmerman F. PACES/HRS expert consensus statement on the evaluation and management of ventricular arrhythmias in the child with a structurally normal heart.Heart Rhythm. 2014; 11: e55-e78Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar This document was reviewed and approved by the PACES executive committee and the Scientific and Clinical Documents Committee of HRS. All the writing members approved the final version. Author and reviewer disclosures are provided in Appendix 1, Appendix 2, respectively.Appendix 1Author Disclosure TableWriting Group MemberInstitutionConsultant/ Advisory Board/ HonorariaSpeakers’ BureauResearch GrantFellowship SupportStock Options/PartnerBoard Mbs/ OtherJ. Philip Saul, MD, FHRS, FACC, FAHA, FAAPJP Saul Consultingm, Mount Pleasant, SC1; Novartis PharmaceuticalsNoneNoneNoneNoneNoneRonald J. Kanter, MD, FHRS, FACCMiami Childrens Hospital, Coral Gables, FLNoneNoneNoneNoneNoneNoneDominic Abrams, MDRoyal Brompton & Harefield NHS Trust, London, UKNoneNoneNoneNoneNoneEquity Interests: 1; Johnson and JohnsonSamuel Asirvatham, MDMayo Clinic, Rochester, MN1; Biotronik, Abiomed; Boston Scientific Corp; Medtronic, Inc.; Sanofi Aventis; St. Jude Medical; Stereotaxis, Inc.; Spectranetics Corporation; Mediasphere Medical; Biosense Webster, Inc.; AtriCure, Inc.; Wolters Kluver; ElsevierNoneNoneNoneNoneNoneYaniv Bar-Cohen, MD, FAAP, FACCChildren’s Hospital of Los Angeles, Los Angeles, CANoneNoneNoneNoneNoneNoneAndrew D. Blaufox, MD, FHRS, FACCAlexandra & Steven Cohen Children’s Medical Center of NY, New Hyde Park, NY1; Boehringer IngelheimNoneNoneNoneNoneNoneBryan Cannon, MDMayo School of Graduate Medical Education, Rochester, MN1; St. Jude Medical; Medtronic, Inc.NoneNoneNoneNoneNoneJohn Clark, MDAkron Children’s Hospital, Akron, OH1; St. Jude MedicalNoneNoneNoneNoneNoneMacdonald Dick, MD, FHRS, FACCUniv of Michigan Health Systems, Ann Arbor, MI1; Pfizer, Inc.NoneNoneNoneNoneNoneAnne Freter, MSN, FHRSAdvocate Medical Group, Wheaton, ILNoneNoneNoneNoneNoneNoneNaomi J. Kertesz, MD, FACC, FHRSNationwide Children’s Hospital, Columbus, OH1; Medtronic, Inc.NoneNoneNoneNoneNoneJoel A. Kirsh, MD, FRCP, FHRS, CEPHospital for Sick Children, Toronto, ONNoneNoneNoneNoneNoneNoneJohn Kugler, MD, FAAC, FAAP, FAHAUNMC/CU Children’s Hospital, Omaha, NENoneNoneNoneNoneNoneNoneMartin LaPage, MD, MS, FAAP, FHRS, CCDS, CEPSUniversity of Michigan, Ann Arbor, MINoneNoneNoneNoneNoneNoneFrancis X. McGowan, MD, FAAPThe Children’s Hospital of Philadelphia, Philadelphia, PAChristina Y. Miyake, MDStanford University, Redwood City, CANoneNoneNoneNoneNoneNoneAruna Nathan, MBBS, FRCAThe Children’s Hospital of Philadelphia, Philadelphia, PAJohn Papagiannis, MD, FHRS, CEPSChildren’s Mercy Hospital, Kansas City, MONoneNoneNoneNoneNoneNoneThomas Paul, MD, FHRS, FACCGeorg-August-Univ Medical Univ Hospital, Gottingen, GermanyNoneNoneNoneNoneNoneNoneAndreas Pflaumer, MD, FRACP, FCSANZ, CEPSRoyal Children’s Hospital Melbourne, AUNoneNoneNone2; St. Jude Medical; Medtronic, Inc.NoneNoneAllan C. Skanes, MD, FRCPCLondon Health Sciences Center, London, ON1; Boehringer Ingelheim; Biosense Webster, Inc.; Medtronic, Inc.None2; Boehringer Ingelheim;3; Biosense Webster, Inc.5; Medtronic, Inc.NoneNoneWilliam G. Stevenson, MD, FAHA, FHRS, FACCBrigham and Women’s Hospital, Boston, MANoneNoneNoneNoneNoneOfficer, trustee, director, or other fiduciary role: 3; American Heart Association; Intellectual Property Rights: Brigham and Women’s; Biosense Webster, Inc.Nicholas Von Bergen, MDThe Children’s Hospital of Iowa, Iowa City, IANoneNoneNoneNoneNoneNoneFrank Zimmerman, MD, FAHA, FHRSThe Heart Institute for Children, Western Springs, ILNoneNoneNoneNoneNoneNoneNumber Value: 0 = $0; 1 = < $10,000; 2 = > $10,000 to < $25,000; 3 = > $25,000 to < $50,000; 4 = > $50,000 to < $100,000; 5 = > $100,000 Open table in a new tab Appendix 2Peer-Reviewers Disclosure TablePeer ReviewerInstitutionConsultant/ Advisory Board/ HonorariaSpeakers’ BureauResearch GrantFellowship SupportStock Options/PartnerBoard Mbs/ OtherJames PerryUCSD Rady Children’s Hospital, San Diego, CA1; Medical Legal ConsultingNoneNoneNoneNoneNoneSusan EtheridgeUniversity of Utah, Department of Pediatric Cardiology, Salt Lake City, UTNoneNoneNoneNoneNoneNoneDipen ShahHopital Cantonal De Geneve, Thonex, Switzerland1; Biosense Webster, Inc. Biotronick; 2; Endosense1; Endosense;2; Endosense3; Bard Electrophysiology; Biotronik; St. Jude Medical; 4; Biosense Webster, Inc.None1; EndosenseNoneCharles BerulChildren’s National Medical Center, Washington DCNoneNone4; Medtronic, Inc.NoneNoneNoneBarbara DealChildren’s Hospital of ChicagoNoneNoneNoneNoneNoneNoneAndrew M. DavisThe Royal Children’s Hospital, MelbourneNoneNoneNone3; Medtronic, Inc.; St. Jude MedicalNoneNoneJonathan SkinnerStarship Hospital, Paediatric Cardiology, Auckland, NZ0; Medtronic, Inc.NoneNoneNoneNoneNoneLouise HarrisUniversity of Toronto, Peter Munk Cardiac Centre, Toronto, ON1; St. Jude MedicalNoneNoneNoneNoneNoneJuha-Matti HapponenHelsinki University Central Hospital, Helsinki, Uusimaa, Finland1; St. Jude MedicalNoneNoneNoneNoneNoneFabrizio DragoBambino Gesù Children׳s Hospital, Rome, ItalyNoneNoneNoneNoneNoneNoneThomas KriebelGeorg-August-University Göttingen, Göttingen, Germany1; AOP OrphanNoneNoneNoneNoneNoneLaszlo KornyeiGottsegen Gyorgy Hungarian Institute of Cardiology, Budapest, HungaryNoneNoneNoneNoneNoneNoneNumber Value: 0 = $0; 1 = < $10,000; 2 = > $10,000 to < $25,000; 3 = > $25,000 to < $50,000; 4 = > $50,000 to < $100,000; 5 = > $100,000 Open table in a new tab Number Value: 0 = $0; 1 = < $10,000; 2 = > $10,000 to < $25,000; 3 = > $25,000 to < $50,000; 4 = > $50,000 to < $100,000; 5 = > $100,000 Number Value: 0 = $0; 1 = < $10,000; 2 = > $10,000 to < $25,000; 3 = > $25,000 to < $50,000; 4 = > $50,000 to < $100,000; 5 = > $100,000 Multicenter data from the Pediatric Electrophysiology Society were first reported in 1994 from the Pediatric Electrophysiology Catheter Ablation Registry.6Kugler J.D. Danford D.A. Deal B.J. Gillette P.C. Perry J.C. Silka M.J. Van Hare G.F. Walsh E.P. Radiofrequency catheter ablation for tachyarrhythmias in children and adolescents. The Pediatric Electrophysiology Society.N Engl J Med. 1994; 330: 1481-1487Crossref PubMed Scopus (264) Google Scholar Data from within the same registry were subsequently compared from two separate eras of radiofrequency (RF) ablation only, 1991–1995 (Early Era, n = 4193 procedures) and 1996–1999 (Late Era, n = 3407 procedures). The results from all substrates showed an improvement in the success rate from 90.4% in the Early Era to 95.2% in the Late Era.7Kugler J.D. Danford D.A. Houston K.A. Felix G. Pediatric Radiofrequency Ablation Registry of the Pediatric Radiofrequency Ablation Registry of the Pediatric Electrophysiology Society. Pediatric radiofrequency catheter ablation registry success, fluoroscopy time, and complication rate for supraventricular tachycardia: comparison of early and recent eras.J Cardiovasc Electrophysiol. 2002; 13: 336-341Crossref PubMed Google Scholar Beginning in 2000, data were prospectively collected as part of the Prospective Assessment after Pediatric Cardiac Ablation (PAPCA) study, again only for RF ablation.8Van Hare G.F. Carmelli D. Smith W.M. Kugler J. Silka M. Friedman R. Atkins D. Saul P. Schaffer M. Byrum C. Dunnigan A. Colan S. Serwer G. Pediatric Electrophysiology Society. Prospective assessment after pediatric cardiac ablation: design and implementation of the multicenter study.Pacing Clin Electrophysiol. 2002; 25: 332-341Crossref PubMed Google Scholar A total of 2761 ablation patients from 41 centers were prospectively enrolled, of whom 481 followed a standard protocol for a period of two years.9Van Hare G.F. Javitz H. Carmelli D. Saul J.P. Tanel R.E. Fischbach P.S. Kanter R.J. Schaffer M. Dunnigan A. Colan S. Serwer G. Prospective assessment after pediatric cardiac ablation: demographics, medical profiles, and initial outcomes.J Cardiovasc Electrophysiol. 2004; 15: 759-770Crossref PubMed Scopus (170) Google Scholar The initial success rate for all the supraventricular tachycardia (SVT) substrates was 93%. Accessory pathway (AP) ablation success was 94% (left freewall 98%; right freewall 90%; left septal 88%; right septal 89%), AVNRT 99%, atrial ectopic focus 93%, junctional ectopic tachycardia (JET) 100%, and ventricular tachycardia (VT) 78%. Recurrence at 12 months was related to the substrate and was highest for right-sided APs (24.6% right septal; 15.8% right freewall) compared with left-sided pathways (9.3% left freewall; 4.8% left septal). Recurrence was lowest for AVNRT at 4.8%.10Van Hare G.F. Javitz H. Carmelli D. Saul J.P. Tanel R.E. Fischbach P.S. Kanter R.J. Schaffer M. Dunnigan A. Colan S. Serwer G. Participating Members of the Pediatric Electrophysiology Society. Prospective assessment after pediatric cardiac ablation: recurrence at 1 year after initially successful ablation of supraventricular tachycardia.Heart Rhythm. 2004; 1: 188-196Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar A more recent multicenter report in 2014 from three Czech Republic centers included 708 procedures in 633 pediatric patients and showed somewhat lower acute and long-term success rates for AP ablation and AVNRT.11Kubuš P. Vít P. Gebauer R.A. Zaoral L. Peichl P. Fiala M. Janousek J. Long-term results of paediatric radiofrequency catheter ablation: a population-based study.Europace. 2014; 16: 1808-1813Crossref PubMed Scopus (2) Google Scholar There are no registry or prospective trial data for the use of cryoablation in the pediatric population. There is evidence that with increased experience and improved technology, the number of acute procedural complications can be reduced (e.g., from 4.2% in 1991–1995 to 3% in 1996–1999); however, there are no studies systematically capturing all short- and long-term risks of catheter ablation.7Kugler J.D. Danford D.A. Houston K.A. Felix G. Pediatric Radiofrequency Ablation Registry of the Pediatric Radiofrequency Ablation Registry of the Pediatric Electrophysiology Society. Pediatric radiofrequency catheter ablation registry success, fluoroscopy time, and complication rate for supraventricular tachycardia: comparison of early and recent eras.J Cardiovasc Electrophysiol. 2002; 13: 336-341Crossref PubMed Google Scholar Death and major complications are rare, but are more frequent when there is underlying heart disease, lower patient weight, greater number of RF applications, and left-sided procedures.12Schaffer M.S. Gow R.M. Moak J.P. Saul J.P. Mortality following radiofrequency catheter ablation (from the Pediatric Radiofrequency Ablation Registry). Participating Members of the Pediatric Electrophysiology Society.Am J Cardiol. 2000; 86: 639-643Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar The three most common serious complications, defined as requiring emergency or ongoing treatment, were AV block (second and/or third degree), catheter perforation or pericardial effusion, and thrombi or emboli. When analyzed for all ages from the Early to the Late Era, rates were lower in the Late Era, but no significant differences were found for any complication:7Kugler J.D. Danford D.A. Houston K.A. Felix G. Pediatric Radiofrequency Ablation Registry of the Pediatric Radiofrequency Ablation Registry of the Pediatric Electrophysiology Society. Pediatric radiofrequency catheter ablation registry success, fluoroscopy time, and complication rate for supraventricular tachycardia: comparison of early and recent eras.J Cardiovasc Electrophysiol. 2002; 13: 336-341Crossref PubMed Google Scholar Early Era vs Late Era: AV block, 36 of 4050 (0.89%) vs 18 of 3187 (0.56%), P = .14; perforation or effusion: 28 of 4050 (0.69%) vs 17 of 3187 (0.53%), P = .40; thrombi or emboli: 15 of 4050 (0.37%) vs 6 of 3187 (0.19%), P = .15. In the PAPCA registry,9Van Hare G.F. Javitz H. Carmelli D. Saul J.P. Tanel R.E. Fischbach P.S. Kanter R.J. Schaffer M. Dunnigan A. Colan S. Serwer G. Prospective assessment after pediatric cardiac ablation: demographics, medical profiles, and initial outcomes.J Cardiovasc Electrophysiol. 2004; 15: 759-770Crossref PubMed Scopus (170) Google Scholar the complication of AV block persisted, with a rate of 1.2 % compared with the 0.56% in the preceding Late Era registry.7Kugler J.D. Danford D.A. Houston K.A. Felix G. Pediatric Radiofrequency Ablation Registry of the Pediatric Radiofrequency Ablation Registry of the Pediatric Electrophysiology Society. Pediatric radiofrequency catheter ablation registry success, fluoroscopy time, and complication rate for supraventricular tachycardia: comparison of early and recent eras.J Cardiovasc Electrophysiol. 2002; 13: 336-341Crossref PubMed Google Scholar The highest rates were with AVNRT at 2.0% and septal APs at 3.0%. Although not included in any registries, the increased use of cryoablation for substrate targets in the septal areas (slow AV node pathway for AVNRT; anterior and mid-septal APs) appears to be associated with much lower AV nodal injury rates (see the cryo discussion in Section 3.3). Three procedural deaths occurred (two APs; one atrial ectopic focus) in the Early Era compared with one procedural death (AP) in the Late Era (P = .31).12Schaffer M.S. Gow R.M. Moak J.P. Saul J.P. Mortality following radiofrequency catheter ablation (from the Pediatric Radiofrequency Ablation Registry). Participating Members of the Pediatric Electrophysiology Society.Am J Cardiol. 2000; 86: 639-643Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar No deaths were recorded during the PAPCA registry years or from the recent Czech multicenter retrospective study.11Kubuš P. Vít P. Gebauer R.A. Zaoral L. Peichl P. Fiala M. Janousek J. Long-term results of paediatric radiofrequency catheter ablation: a population-based study.Europace. 2014; 16: 1808-1813Crossref PubMed Scopus (2) Google Scholar Minor complications such as pseudoaneurysms, arteriovenous fistula, and minor bleeding are typically not reported in randomized or prospective studies; however, some reports on the pediatric population mention a 1%–3% incidence of minor vascular complications,11Kubuš P. Vít P. Gebauer R.A. Zaoral L. Peichl P. Fiala M. Janousek J. Long-term results of paediatric radiofrequency catheter ablation: a population-based study.Europace. 2014; 16: 1808-1813Crossref PubMed Scopus (2) Google Scholar, 13Hanslik A. Mujagic A. Mlczoch E. Gössinger H. Gwechenberger M. Richter B. Marx M. Albinni S. Radiofrequency catheter ablation can be performed with high success rates and very low complication rates in children and adolescents.Acta Paediatrica. 2014; 103: e188-e193Crossref PubMed Google Scholar, 14Mosaed P. Dalili M. Emkanjoo Z. Interventional electrophysiology in children: a single-center experience.Iranian J Pediatr. 2012; 22: 333-338PubMed Google Scholar and studies on adult patients note minor vascular complications of up to 5%.15Prudente L.A. Moorman J.R. Lake D. Xiao Y. Greebaum H. Mangrum J.M. DiMarco J.P. Ferguson J.D. Femoral vascular complications following catheter ablation of atrial fibrillation.J Interv Cardiac Electrophysiol. 2009; 26: 59-64Crossref PubMed Scopus (0) Google Scholar Although there are some data that congenital heart disease might increase the risk of a vascular complication,16Maxwell B.G. Steppan J. Cheng A. Complications of catheter-based electrophysiology procedures in adults with congenital heart disease: a national analysis.J Cardiothorac Vasc Anesth. 2015; 29: 258-264Abstract Full Text Full Text PDF PubMed Google Scholar there are no controlled studies directly supporting this observation. Thrombosis and embolism are always a concern during invasive procedures, but reports are anecdotal. Severe complications, such as acute coronary sinus thrombosis, have been reported.17Yeo K.K. Davenport J. Raff G. Laird J.R. Life-threatening coronary sinus thrombosis following catheter ablation: case report and review of literature.Cardiovas Revasc Med. 2010; 11 (262.e261–e265)Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Recent findings from MRIs routinely performed on adults after atrial ablation raise concerns about the risk of microembolisms that could cause brain lesions, but there are no reports on children to date. High energy delivery and poor electrode tissue contact appear to be risk factors in adults.18Nagy-Balo E. Kiss A. Condie C. Stewart M. Edes I. Csanadi Z. Predictors of cerebral microembolization during phased radiofrequency ablation of atrial fibrillation: analysis of biophysical parameters from the ablation generator.Heart Rhythm. 2014; 11: 977-983Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Direct injury due to ablation energy can cause damage to all adjacent structures, such as the esophagus, the coronary arteries, and the phrenic nerve. Again, there are no systematic reviews, but studies on adults and animals suggest a relationship to certain regions, higher energy levels, and multiple applications.19Bohnen M. Stevenson W.G. Tedrow U.B. Michaud G.F. John R.M. Epstein L.M. Albert C.M. Koplan B.A. Incidence and predictors of major complications from contemporary catheter ablation to treat cardiac arrhythmias.Heart Rhythm. 2011; 8: 1661-1666Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar Coronary artery spasm, stenosis, and occlusion have been reported in almost all AV groove locations except the anterior, where the coronary arteries are larger and further from the groove.20Blaufox A.D. Saul J.P. Acute coronary artery stenosis during slow pathway ablation for atrioventricular nodal reentrant tachycardia in a child.J Cardiovasc Electrophysiol. 2004; 15: 97-100Crossref PubMed Scopus (38) Google Scholar, 21Ouali S. Anselme F. Savoure A. Cribier A. Acute coronary occlusion during radiofrequency catheter ablation of typical atrial flutter.J Cardiovasc Electrophysiol. 2002; 13: 1047-1049Crossref PubMed Google Scholar, 22Khanal S. Ribeiro P.A. Platt M. Kuhn M.A. Right coronary artery occlusion as a complication of accessory pathway ablation in a 12–year-old treated with stenting.Catheter Cardiovasc Interv. 1999; 46: 59-61Crossref PubMed Google Scholar, 23Spar D.S. Silver E.S. Hordof A.J. Torres A. Liberman L. Coronary artery spasm during radiofrequency ablation of a left lateral accessory pathway.Pediatric Cardiol. 2010; 31: 724-727Crossref PubMed Scopus (0) Google Scholar Details from pre- and post-ablation coronary angiography in a pediatric SVT ablation series are reviewed in Section 3.2;24Schneider H.E. Kriebel T. Gravenhorst V.D. Paul T. Incidence of coronary artery injury immediately after catheter ablation for supraventricular tachycardias in infants and children.Heart Rhythm. 2009; 6: 461-467Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar however, angiography is typically not routinely performed after ablation, thus the risk of asymptomatic stenosis might be underestimated. Reports of echocardiogram findings have not shown any obvious wall motion or significant valve abnormalities.25Van Hare G.F. Colan S.D. Javitz H. Carmelli D. Knilans T. Schaffer M. Kugler J. Byrum C.J. Saul J.P. Participating Members of the Pediatric Electrophysiology Society. Prospective assessment after pediatric cardiac ablation: fate of intracardiac structure and function, as assessed by serial echocardiography.Am Heart J. 2007; 153 (815–820–820.e811–816)Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Cryoablation appears to have a lower risk of coronary injury26Schneider H.E. Stahl M. Kriebel T. Schillinger W. Schill M. Jakobi J. Paul T. Double cryoenergy application (freeze-thaw-freeze) at growing myocardium: lesion volume and effects on coronary arteries early after energy application. Implications for efficacy and safety in pediatric patients.J Cardiovasc Electrophysiol. 2013; 24: 701-707Crossref PubMed Google Scholar (see Section 3.3). There is general concern based on animal studies that both RF and cryoablation lesions in young children might grow after the procedure27Saul J.P. Hulse J. Papagiannis J. Van Praagh R. Walsh E. Late enlargement of radiofrequency lesions in infant lambs. Implications for ablat