See what happens and avoid complications in real life

• what kind of complication can be expected during CTI ablation
• how to avoid them
• what critical warnings can not be overlooked

The first step of avoiding complications is to be aware of this possibility. Catheter ablation of the CTI is generally a safe and effective procedure for treating typical atrial flutter. However, like any invasive procedure, it carries the risk of complications. Here are some typical complications associated with CTI ablation:

• A too medial ablation line can accidentally be drawn in the vicinity of AV node region and therefore cause AV block. Such complication is most likely to occur at the beginning of ablation line which starts in most cases at tricuspid valve anulus. In this region you should pay extra attention that the catheter does not drift medial or upwards. You can control that using fluoroscopy or 3D mapping system.  Be very cautious about signals indicating AV node or His region (i.e. His potential or junctional beats).
• An extremely dangerous complication is a perforation of V. cava inferior due to extended ablation. Such complication leads to bleeding that can be underdiagnose due to its non-specific symptoms (hemorrhagic shock) and difficult diagnostic (CT or MRI). Therefore surgical procedure might came too late. In order to avoid such event, you should pay a close attention to signals at the end of the ablation line (avoid far-field signals) and the characteristic movement of the catheter when it drops from RA to V. cava. You might try this movement without ablation few times in order to get the feeling of it. The last critical warning comes in form of extreme pain reaction that should not be ignored. Even by sedated patient such pain reaction might be indicated by involuntary movement that can cause surface ECG artefacts.
• During any kind of ablation an extreme increase of tissue temperature can cause gas formation within the tissue and a subsequent abrupt escape of it in form of explosion called steam pop. Such event can be omitted by cautious titration of the energy and (to some extent) use of irrigated catheters.

CAVE: general complications like groin access related one or thromboembolism, etc. have not been mentioned.