Incidence and predictors of silent cerebral embolism during pulmonary vein catheter ablation for atrial fibrillation.

AIMS Left atrial catheter ablation of the pulmonary veins (PV) has evolved as an important therapeutic option for the treatment of atrial fibrillation (AF). We aimed to investigate the incidence and predictors of silent cerebral embolism associated with PV catheter ablation, detected by diffusion-weighted magnetic resonance imaging (DW-MRI). METHODS AND RESULTS We performed a prospective analysis of 53 consecutive patients with persistent or paroxysmal AF that underwent PV ablation and post-procedural cerebral MRI 1 day after lasso catheter-guided ostial PV ablation. Patients were analysed for possible demographical, medical, echocardiographical, and procedural predictors of embolic events. A mean of 3.5 +/- 0.5 PVs were ablated per patient. In six patients, DW-MRI depicted new clinically silent microembolism after PV ablation (11%). The number of ineffective medical antiarrhythmic agents prior to ablation procedure was significantly higher in the embolism group (3.3 +/- 0.5 vs. 2.2 +/- 1.4, P = 0.014). Coronary heart disease (CAD) was more frequent in patients with cerebral embolisms (33 vs. 2%, P = 0.031); left ventricular volume (130 +/- 12 vs. 103 +/- 26 mL, P = 0.002), and septal wall thickness (13.0 +/- 1.4 vs. 7.9 +/- 4.8 mm, P = 0.025) were significantly increased. CONCLUSION This study shows a high incidence of silent micro-embolic events after PV ablation. CAD, left ventricular dilatation, and hypertrophy were potential predictors of this complication.

[1]  Burr Hall,et al.  Catheter Ablation for Paroxysmal Atrial Fibrillation: Segmental Pulmonary Vein Ostial Ablation Versus Left Atrial Ablation , 2003, Circulation.

[2]  E. Downar,et al.  Thrombogenicity of radiofrequency ablation procedures: what factors influence thrombin generation? , 2001, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[3]  H. Crijns,et al.  Pulmonary vein isolation using transvenous catheter cryoablation for treatment of atrial fibrillation without risk of pulmonary vein stenosis. , 2003, Journal of the American College of Cardiology.

[4]  D. Haines,et al.  Cerebrovascular Complication Associated with Pulmonary Vein Ablation , 2002, Journal of cardiovascular electrophysiology.

[5]  H. Calkins,et al.  Predictors of Recurrence Following Catheter Ablation of Atrial Fibrillation Using an Irrigated‐Tip Ablation Catheter , 2004, Journal of cardiovascular electrophysiology.

[6]  Douglas Packer,et al.  Worldwide Survey on the Methods, Efficacy, and Safety of Catheter Ablation for Human Atrial Fibrillation , 2005, Circulation.

[7]  F. Marchlinski,et al.  Left atrial thrombus associated with ablation for atrial fibrillation: identification with intracardiac echocardiography. , 2004, Journal of the American College of Cardiology.

[8]  Prashanthan Sanders,et al.  Catheter ablation for atrial fibrillation in congestive heart failure. , 2004, The New England journal of medicine.

[9]  R. Mantovan,et al.  Early complications of pulmonary vein catheter ablation for atrial fibrillation: a multicenter prospective registry on procedural safety. , 2007, Heart rhythm.

[10]  Rolf Fimmers,et al.  Silent and apparent cerebral embolism after retrograde catheterisation of the aortic valve in valvular stenosis: a prospective, randomised study , 2003, The Lancet.

[11]  C. Tai,et al.  Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. , 1999, Circulation.

[12]  J. Ruskin,et al.  HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. , 2007, Heart rhythm.

[13]  A. Norbash,et al.  Silent thromboembolic events associated with the treatment of unruptured cerebral aneurysms by use of Guglielmi detachable coils: prospective study applying diffusion-weighted imaging. , 2001, AJNR. American journal of neuroradiology.

[14]  J Clémenty,et al.  Electrophysiological Breakthroughs From the Left Atrium to the Pulmonary Veins , 2000, Circulation.

[15]  H. Calkins,et al.  Radiofrequency ablation for atrial fibrillation , 2002, Current treatment options in cardiovascular medicine.

[16]  B. Lüderitz,et al.  Cerebral Diffusion‐Weighted Magnetic Resonance Imaging: A Tool to Monitor the Thrombogenicity of Left Atrial Catheter Ablation , 2005, Journal of cardiovascular electrophysiology.

[17]  Vincenzo Santinelli,et al.  The Who, What, Why, and How‐To Guide for Circumferential Pulmonary Vein Ablation , 2004, Journal of cardiovascular electrophysiology.

[18]  J. Ruskin,et al.  Thromboembolic Complications of Cardiac Radiofrequency Catheter Ablation , 1999, Journal of cardiovascular electrophysiology.

[19]  G. Hindricks,et al.  Venice Chart International Consensus Document on Atrial Fibrillation Ablation , 2007, Journal of cardiovascular electrophysiology.

[20]  David Keane,et al.  Efficacy and Safety of Segmental Ostial Versus Circumferential Extra‐Ostial Pulmonary Vein Isolation for Atrial Fibrillation , 2004, Journal of cardiovascular electrophysiology.

[21]  P. Tchou,et al.  Circular mapping and ablation of the pulmonary vein for treatment of atrial fibrillation: impact of different catheter technologies. , 2002, Journal of the American College of Cardiology.

[22]  Hakan Oral,et al.  Pulmonary Vein Isolation for Paroxysmal and Persistent Atrial Fibrillation , 2002, Circulation.

[23]  Atul Verma,et al.  Transcranial Doppler Detection of Microembolic Signals During Pulmonary Vein Antrum Isolation: Implications for Titration of Radiofrequency Energy , 2006, Journal of cardiovascular electrophysiology.

[24]  M. Koltzenburg,et al.  Silent embolism in diagnostic cerebral angiography and neurointerventional procedures: a prospective study , 1999, The Lancet.

[25]  D. Lin,et al.  Increased Intensity of Anticoagulation May Reduce Risk of Thrombus During Atrial Fibrillation Ablation Procedures in Patients with Spontaneous Echo Contrast , 2005, Journal of cardiovascular electrophysiology.

[26]  A. Russo,et al.  Mechanisms of Organized Left Atrial Tachycardias Occurring After Pulmonary Vein Isolation , 2004, Circulation.

[27]  Elia Biganzoli,et al.  Updated Worldwide Survey on the Methods, Efficacy, and Safety of Catheter Ablation for Human Atrial Fibrillation , 2005, Circulation. Arrhythmia and electrophysiology.

[28]  M. Mansour.  Learning While Burning: , 2004, Journal of cardiovascular electrophysiology.

[29]  D. Saloner,et al.  Detection of clinically silent infarcts after carotid endarterectomy by use of diffusion-weighted imaging. , 2001, AJNR. American journal of neuroradiology.

[30]  P. Coumel,et al.  High‐Flow Perfusion of Sheaths for Prevention of Thromboembolic Complications During Complex Catheter Ablation in the Left Atrium , 2004, Journal of cardiovascular electrophysiology.

[31]  S Chierchia,et al.  Circumferential Radiofrequency Ablation of Pulmonary Vein Ostia: A New Anatomic Approach for Curing Atrial Fibrillation , 2000, Circulation.

[32]  Hirotsugu Yamada,et al.  Phased-Array Intracardiac Echocardiography Monitoring During Pulmonary Vein Isolation in Patients With Atrial Fibrillation: Impact on Outcome and Complications , 2003, Circulation.

[33]  H. Calkins,et al.  Safety and efficacy of circumferential pulmonary vein catheter ablation of atrial fibrillation. , 2005, Heart rhythm.

[34]  D. Noble,et al.  Cellular Na+ Homeostasis in the Mammalian Heart: Relationship to Altered Contractility, Rhythm Disturbances, and Defects in Myocyte Metabolism , 2006, Journal of cardiovascular electrophysiology.

[35]  J Clémenty,et al.  [Catheter ablation of paroxysmal atrial fibrillation]. , 2004, Archives des maladies du coeur et des vaisseaux.

[36]  G. Schroth,et al.  Silent cerebral ischemia detected by diffusion-weighted MRI after carotid endarterectomy. , 2000, Stroke.