Asymptomatic Cerebral Infarction During Catheter Ablation for Atrial Fibrillation

Kimura, Tokuhiro; Kashimura, Shin; Nishiyama, Takahiko; Katsumata, Yoshinori; Inagawa, Kohei; Ikegami, Yasuyuki; Nishiyama, Nobuhiro; Fukumoto, Kotaro; Tanimoto, Yoko; Aizawa, Yoshifusa; Tanimoto, Kojiro; Fukuda, Keiichi; Takatsuki, Seiji

doi:10.1016/j.jacep.2018.08.003

Cited by 33 publications

(37 citation statements)

References 34 publications

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“…Previous studies demonstrated that the uninterrupted OAC minimized the risk of SCEs during AF ablation compared with interrupted OAC 4 ; expert consensus and guidelines first recommend the use of NOACs or VKA without interruption during the procedure 12 . However, recent studies have reported that the incidence of MRI‐detected SCEs still hovers at 2% to 27.2% in patients on uninterrupted OAC for AF ablation 5,13–17 . In the present study, the SCE incidence remains at 23.1% in total and was almost similar to or even higher than the incidence in the previous studies.…”

Section: Discussionsupporting

confidence: 59%

“…However, these factors were identified in patients taking only VKA, but not NOACs. Kimura et al 17 demonstrated that the presence of deep and subcortical white matter hyperintensity and the frequency of cardioversions were associated with SCEs in patients taking rivaroxaban or VKA without interruption during the procedure. In this study, Age, LAD, baseline ACT before UFH injection, and time to reach the optimal ACT were significant risk factors for SCEs.…”

Section: Discussionmentioning

confidence: 99%

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Factors associated with silent cerebral events during atrial fibrillation ablation in patients on uninterrupted oral anticoagulation

Harada

Motoike

Nomura

et al. 2020

Cardiovasc electrophysiol

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Introduction Silent cerebral events (SCEs) are related to the potential thromboembolic risk in atrial fibrillation (AF) ablation. Periprocedural uninterrupted oral anticoagulation (OAC) reportedly reduced the risk of SCEs, but the incidence still remains. Methods and Results AF patients undergoing catheter ablation were eligible. All patients took non–vitamin K antagonist oral anticoagulants (NOACs; n = 248) or vitamin K antagonist (VKA; n = 37) for periprocedural OAC (>4 weeks) without interruption during the procedure. Brain magnetic resonance imaging was performed within 2 days after the procedure to detect SCEs. Clinical characteristics and procedure‐related parameters were compared between patients with and without SCEs. SCEs were detected in 66 patients (23.1%; SCE[+]) but were not detected in 219 patients (SCE[−]). Age was higher in SCE[+] than in SCE[−] (66 ± 10 vs. 62 ± 12 years; p < .05). Persistent AF prevalence, CHADS2/CHA2DS2‐VASc scores, serum NT‐ProBNP levels, left atrial dimension (LAD), and spontaneous echo contrast prevalence in transesophageal echocardiography significantly increased in SCE[+] versus SCE[−]. SCE[+] had lower baseline activated clotting time (ACT) before heparin injection and longer time to reach optimal ACT (>300 s) than SCE[−] (146 ± 27 vs. 156 ± 29 s and 44 ± 30 vs. 35 ± 25 min; p < .05, respectively). In multivariate analysis, age, LAD, baseline ACT, and time to reach the optimal ACT were predictors for SCEs. The average values of the ACT parameters were significantly different among NOACs/VKA. Conclusion Age, LAD, and intraprocedural ACT kinetics significantly affect SCEs during AF ablation. Different anticoagulants have different impacts on ACT during the procedure, which should be considered when estimating the risk of SCEs.

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Section: Discussionsupporting

confidence: 59%

Section: Discussionmentioning

confidence: 99%

Factors associated with silent cerebral events during atrial fibrillation ablation in patients on uninterrupted oral anticoagulation

Harada

Motoike

Nomura

et al. 2020

Cardiovasc electrophysiol

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“…The major bleeding events of uninterrupted NOACs and uninterrupted warfarin groups were reported in all included studies. Five studies [9][10][11]13,14] applied the International Society on Thrombosis and Hemostasis (ISTH) de nition [15] for major bleeding, except the ASCERTAIN study [12] . There was a moderate heterogeneity, so a xed-effect model was used.…”

Section: Results Of the Meta-analysismentioning

confidence: 99%

“…Six published studies [9][10][11][12][13][14] including 2392 patients were identi ed for inclusion in the analysis. The process of study selection is summarized in Figure 1.…”

Section: Characteristics Of the Included Studiesmentioning

confidence: 99%

Comparison of Major Bleeding Events of Uninterrupted Novel Oral Anticoagulants Versus Uninterrupted Vitamin K Antagonist During Catheter Ablation of Atrial Fibrillation: A Meta-analysis of Randomized Controlled Trials

Yang

Chen

Zhai

et al. 2021

Preprint

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Background: Previous meta-analyses comparing efficacy and safety of uninterrupted novel oral anticoagulants (NOACs) versus uninterrupted vitamin K antagonist (VKA) during catheter ablation (CA) of atrial fibrillation (AF) had no consensus in major bleeding, and didn’t perform subgroup analyses for different types of major bleeding events. This meta-analysis was performed to comprehensively evaluate the risk of major bleeding events of these two anticoagulant strategies during CA of AF.Methods: We searched online databases for randomized controlled trials that compared major bleeding events of uninterrupted NOACs and VKA during CA of AF up to January 2021. A fixed-effect model was used if the chi-squared test P-value was > 0.10 and I2 was < 50%, otherwise a random- effect model was used.Results: Six published studies including 2392 patients were identified for inclusion in the analysis. The overall incidence of major bleeding events was lower in the NOACs group than in the VKA group (OR = 0.56, 95% CI = 0.34 – 0.93, I2 = 38%, P = 0.15). Subgroup analyses showed that the incidence of severe puncture site complications was lower in the NOACs group than in the VKA group (OR = 0.53, 95% CI = 0.30 – 0.96, I2 = 16%, P = 0.32). But the incidence of cardiac tamponade (OR = 0.53, 95% CI = 0.23 – 1.26, I2 = 0%, P = 0.46), intracranial (OR = 0.25, 95% CI = 0.03 – 2.23, I2 = 0%, P = 0.82) and gastrointestinal bleeding (OR = 0.98, 95% CI = 0.18 – 5.39, I2 = 0%, P = 0.43) had no statistically significant differences between the two groups.Conclusion: This meta-analysis suggests that compared to uninterrupted VKA, uninterrupted NOACs are superior in major bleeding and severe puncture site complications during CA of AF, but are not superior in cardiac tamponade, intracranial and gastrointestinal bleeding.

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“…Further evidence regarding different anticoagulation strategies and their relation to the asymptomatic cerebral infarction (silent brain ischemic lesions in magnetic resonance imaging) rate comes from the ASCERTAIN trial [10] conducted by Kimura, T et al This was a randomized, two-center, assessor-blind study that compared uninterrupted rivaroxaban vs uninterrupted warfarin strategies using an enhanced methodology different from other studies previously described in this section of the article: MRI was performed twice during the periprocedural period -within 2 weeks before (pre-AF ablation MRI) and the day after (post-AF ablation MRI) -to exclude the possibility of attributing older, pre-ablative lesions to those associated with the procedure. A total of 127 patients were enrolled in the study.…”

Section: Safety and Efficacy Of Interrupted Vs Uninterrupted Direct Omentioning

confidence: 99%

Anticoagulation during atrial fibrillation ablation periprocedural period- an update.

Maciejewski¹,

Peller²,

Grabowski³

et al. 2020

Heart Beat

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Atrial fibrillation (AF) is the most common arrhythmia diagnosed in clinical practice and is often treated with pulmonary vein isolation (PVI). This procedure has both high bleeding and thromboembolic risk; therefore well evidenced anticoagulation protocols are important. The anticoagulation strategy in patients undergoing PVI is described in the Expert Consensus. We analyzed studies released after 2018 pertaining to anticoagulation during PVI. Different anticoagulation approaches for AF ablation were studied. New evidence on edoxaban and apixaban for PVI emerged. Direct oral anticoagulants (DOACs) seemed to be safer in terms of bleeding risk and equally effective in stroke prevention compared to vitamin K antagonists (VKAs) according to one metanalysis. Uninterrupted and interrupted anticoagulation strategies with novel oral anticoagulants (NOACs) were studied and brought conflicting results. The "dabigatran bridge" strategy for PVI was tested. New knowledge on the occurrence and clinical significance of silent brain ischemic lesions after PVI is described. An alternative heparin dosing strategy during PVI in patients on NOACs was proposed.

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Asymptomatic Cerebral Infarction During Catheter Ablation for Atrial Fibrillation

Cited by 33 publications

References 34 publications

Factors associated with silent cerebral events during atrial fibrillation ablation in patients on uninterrupted oral anticoagulation

Factors associated with silent cerebral events during atrial fibrillation ablation in patients on uninterrupted oral anticoagulation

Comparison of Major Bleeding Events of Uninterrupted Novel Oral Anticoagulants Versus Uninterrupted Vitamin K Antagonist During Catheter Ablation of Atrial Fibrillation: A Meta-analysis of Randomized Controlled Trials

Anticoagulation during atrial fibrillation ablation periprocedural period- an update.

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