Pericarditis
More than 50% of the patients who undergo catheter ablation of AF note some pleuritic chest pain in the first several days following their procedure. It is also common to observe a “trace” pericardial effusion following AF ablation. These largely self-limited manifestations of AF ablation-induced pericarditis are so common and of so little consequence that they are considered as part of the standard clinical course for patients who undergo AF ablation rather than as a complication of the procedure. A small subset of these patients will go on to develop more severe and clinically significant manifestations of pericarditis. In two recent multicenter registries, pericarditis has been reported to occur in 0.1% and 0.6% of patients, respectively.1059,1257 When transmural lesions are generated during catheter ablation of AF, some epicardial inflammation, and therefore some pericarditis, is inevitable. However, more extensive pericarditis can complicate AF ablation procedures both acutely and at some delay. These presentations include Dressler syndrome, pericarditis leading to delayed cardiac tamponade, and constrictive pericarditis.1258,1259,1260 These severe manifestations and consequences of pericarditis presented between 18 days and 3 months after their ablation procedures. The standard international practice for a short hospital stay after AF ablation procedures can contribute to an underappreciation of early postablation pericarditis.
There is currently no evidence to support the use of nonsteroidal anti-inflammatory drugs (NSAIDs) or steroids to prevent AF recurrences. A single bolus injection of low-dose hydrocortisone (100 mg) reduced the incidence of peri-carditis from 2.5% to 1.1% in one recent series from Japan, but no difference in early or late recurrences was found after AF ablation.1261 Another Japanese study also failed to demonstrate a reduction in immediate, early, or midterm AF recurrence with either a low-dose (hydrocortisone 100 mg) or moderate-dose (methylprednisolone 125 mg) single steroid bolus.
Colchicine is currently the cornerstone of pericarditis treatment that occurs outside of the AF ablation setting, although specific data after AF ablation are lacking. In one trial, however, in which patients were randomized to a 3-month course of colchicine (0.5 mg twice daily) or placebo, early recurrence was significantly reduced (33.5% of placebo patients vs 16% for colchicine), and this was strongly associated with a reduction in inflammatory mediators such as IL-6 and C-reactive protein. After a 15-month follow-up, a 37% reduction in the RR of AF recurrence was observed (number needed to treat = 6).985 In a subsequent randomized study of 233 patients with PAF, these investigators reported that the long-term recurrence rate was 31% among the patients treated with colchicine vs 49% among the placebo patients. Colchicine also resulted in an improvement in QOL.986