Does the number of simultaneously activated electrodes during phased RF multielectrode ablation of atrial fibrillation influence the incidence of silent cerebral microembolism?

Wieczorek, M; Hoeltgen, Reinhard; Brueck, Martin

doi:10.1016/j.hrthm.2013.04.005

Cited by 38 publications

(43 citation statements)

References 19 publications

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“…In contrast to other (earlier) studies we have not included the FLAIR sequence, which may misclassify some DWI hyperintense lesions as negative due to the timeline of FLAIR becoming positive (usually over the first 48 hours or longer). This may lead to undertection of (mostly smaller) silent cerebral events in up to 2/3 of lesions [17]. Schmidt et al [8] using the same definition as in our study found comparable silent cerebral event rates (for IrrRF 24%, for Cryo ablation 18% and 24% for EAS ablation).…”

Section: Discussionsupporting

confidence: 70%

Exchanging Catheters Over a Single Transseptal Sheath During Left Atrial Ablation is Associated with a Higher Risk for Silent Cerebral Events

Deneke

Nentwich

Schmitt

et al. 2014

Indian Pacing and Electrophysiology Journal

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BackgroundSilent cerebral events (SCE) have been identified on magnetic resonance imaging (MRI) in asymptomatic patients after atrial fibrillation (AF) ablation. Procedural determinants influencing the risk for SCE still remain unclear.ObjectiveComparing the risk for SCE depending on exchanges of catheters (ExCath) over a single transseptal sheath.Methods88 Patients undergoing pulmonary vein isolation (PVI) only ablation using either single-tip or balloon-based technique underwent pre- and post-ablation cerebral MRI. Ablations were either performed with double transseptal access and without exchanging catheters over the transseptal sheaths (group 1: no ExCath) or after a single transseptal access and exchanges of therapeutic and diagnostic catheters (group 2: ExCath). Differences in regard to SCE rates were analyzed. Multivariate analysis was performed to identify factors related to the risk for SCE.ResultsIncluded patients underwent PVI using single tip irrigated radiofrequency in 41, endoscopic laser balloon in 27 and cryoballoon in 20 cases. Overall SCE were identified in 23 (26%) patients. In group 1 (no ExCath; N=46) 6 patients (13%) and in group 2 (N=42) 17 patients (40%) had documented SCE (p=0.007). The applied ablation technology did not affect SCE rate. In multivariate analysis age (OR 1.1, p=0.03) and catheter exchanges over a single transseptal sheath (OR 12.1, p=0.007) were the only independent predictors of a higher risk for SCE.ConclusionsExchanging catheters over a single transseptal access to perform left atrial ablation is associated with a significantly higher incidence of SCE compared to an ablation technique using different transseptal accesses for therapeutic and diagnostic catheters.

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Section: Discussionsupporting

confidence: 70%

Exchanging Catheters Over a Single Transseptal Sheath During Left Atrial Ablation is Associated with a Higher Risk for Silent Cerebral Events

Deneke

Nentwich

Schmitt

et al. 2014

Indian Pacing and Electrophysiology Journal

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“…While some groups have defined the ''new MRI-detected lesion'' as a hyperintense diffusion-weighted imaging (DWI) lesion with reduced apparent diffusion coefficient (ADC) and T2-weighted fluid-attenuated inverse recovery sequence (FLAIR) positivity, 10,13-17 a few others have used a more sensitive definition without the FLAIR positivity. 11,[18][19][20][21][22][23][24][25][26] There is much controversy regarding the significance of SCLs/SCEs and their long-term consequences. In addition to the structural MRI findings, several recent studies have suggested a strong association with function, correlating SCLs/SCEs and cognitive decline, as well as dementia.…”

Section: Silent Cerebral Lesions or Eventsmentioning

confidence: 99%

Innovative Approaches to Assess the Impact and Steps to Decrease the Neurological Consequences of Ablation

Ponamgi¹,

Yasin²,

Padmanabhan³

et al. 2016

JICRM

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ABSTRACT. Despite continued innovations in catheter design and technique, catheter ablation for atrial fibrillation (AF) is still fraught with a few serious complications-most feared of which is stroke. Although a ''classic'' clinically disabling stroke is less common (about 1%) after AF ablation, many recent studies have identified an increased incidence of asymptomatic ischemic cerebral lesions known as ''silent clinical lesions'' (SCLs) associated with the procedure. As once thought, these new SCLs seen on post-ablation magnetic resonance imaging of the brain were not actually clinically ''silent'' and were shown to have significant clinical and neuropsychiatric effects on these patients in the long term. These SCLs are thought to represent the ''embolic fingerprints'' of the ablation procedure, suggesting involvement and the need for innovation as well as improved safety at multiple levels before, during, and after the procedure. This may require a multimodality approach involving several measures such as having better peri-procedural anticoagulation strategies, using real-time monitoring for markers of neurologic injury, giving meticulous attention to sheath management, using novel energy sources that are less thrombogenic, and finally establishing imaging protocols for timely detection of these lesions post ablation. The current literature is reviewed here to explore such opportunities to improve neurological outcomes of catheter ablation for AF.

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“…[12][13][14] Previous studies using older ablation generator software and delivery of radiofrequency energy in bipolar fashion to all 5 electrode pairs on the PVAC have reported an excess prevalence of ACE lesions on diffusion-weighted MR imaging scans compared other ablation technologies, such as irrigated radiofrequency ablation or cryoballoon catheter ablation. 15,16 New temperature feedback power control algorithms now help to minimize power overshoot, and the important interaction of electrodes 1 and 10 (from electrode pairs 1 and 5) has been better characterized.…”

Section: Article See P 473mentioning

confidence: 99%

“…This supports the notion that thrombus only accounts for a minority of the particulate embolic burden seen in this setting. Techniques to reduce excess heating and char formation have succeeded in reducing the ACE prevalence, 13 suggesting that coagulum/char embolism remains the most concerning perpetrator.…”

Section: Circ Arrhythm Electrophysiolmentioning

confidence: 99%

“…Clinical studies after serial MR images post ablation demonstrate lesion resolution when the lesions are small, but more persistence when lesions are larger. 13,18 It is possible that limitations of spatial resolution of MR imaging (most studies use 4-5-mm slice thickness) account for the disappearance of the acute lesions on follow-up. In the absence of focal neurological deficits, the lesions observed on MRI scans are defined as asymptomatic.…”

Section: Circ Arrhythm Electrophysiolmentioning

confidence: 99%

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Asymptomatic Cerebral Embolism and Atrial Fibrillation Ablation

Haines

2013

Circ: Arrhythmia and Electrophysiology

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R adiofrequency catheter ablation of symptomatic arrhythmias has enjoyed unprecedented growth during the past 2 decades. This has been attributed to its high success rate in the treatment of a variety of arrhythmias with a discrete ablation target and the low complication rate observed in these procedures.1,2 Initial investigators performing radiofrequency catheter ablation were fortunate that the lesions created with this energy source were small and discrete. It was difficult to cause excessive collateral injury. Early recognition of the problem of sudden electric impedance rise and coagulum formation 3 led to a number of strategies and technologies to minimize this occurrence. In contrast to supraventricular tachycardia ablation, catheter ablation of atrial fibrillation has pushed the limits of our ablation technologies and has shifted the ratio of efficacy to risk in an unfavorable direction. 4 Aggressive ablation with extensive linear ablation, ablation of complex fractionated atrial electrograms, and empirical isolation (debulking) of the posterior left atrial wall 5 have improved procedural success in patients with persistent atrial fibrillation. But with a greater volume of myocardial injury and a greater surface area of disrupted left atrial endocardium from the ablation, it is not surprising that procedure-related complications, especially embolic complications, are more prevalent. Article see p 473The initial observations of the appearance of new asymptomatic cerebral embolism (ACE) lesions on diffusion-weighted MR imaging scans after radiofrequency catheter ablation of atrial fibrillation were striking 6,7 but should not have been unanticipated. The ACE lesions observed are attributed to cerebral microembolism and have been widely reported after procedures, such as cardiopulmonary bypass, 8 carotid artery stenting, 9 and trans aortic valve replacement. 10 The fact that ACE lesions have not been reported previously with radiofrequency ablation either has been because of good fortune or simply because of our failure to look. In any case, the issue is now upon us, and it is incumbent on us to define the source of ACE lesions and do the best to mitigate this risk going forward.In this issue of Circulation Arrhythmia and Electro physiology, Nagy-Baló et al 11 describe the occurrence of microembolic signals (MES) on transcranial Doppler during pulmonary vein isolation for the treatment of atrial fibrillation catheter ablation using 2 different ablation technologies and 2 different anticoagulation regimens. They observed that the prevalence of MES was lower in patients being ablated with a cryoballoon ablation catheter compared with patients ablated with a multipolar duty cycle radiofrequency pulmonary vein ablation catheter (PVAC). The difference was specifically attributable to higher MES production during the period of radiofrequency energy delivery with the PVAC compared with the period of cryothermy with the cryoballoon. It is difficult to know whether the higher rate of MES with PVAC might or might no...

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Does the number of simultaneously activated electrodes during phased RF multielectrode ablation of atrial fibrillation influence the incidence of silent cerebral microembolism?

Cited by 38 publications

References 19 publications

Exchanging Catheters Over a Single Transseptal Sheath During Left Atrial Ablation is Associated with a Higher Risk for Silent Cerebral Events

Exchanging Catheters Over a Single Transseptal Sheath During Left Atrial Ablation is Associated with a Higher Risk for Silent Cerebral Events

Innovative Approaches to Assess the Impact and Steps to Decrease the Neurological Consequences of Ablation

Asymptomatic Cerebral Embolism and Atrial Fibrillation Ablation

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