Incidence and Long-Term Follow-Up of Silent Cerebral Lesions After Pulmonary Vein Isolation Using a Remote Robotic Navigation System as Compared With Manual Ablation

Abstract

Background— The incidence of silent cerebral lesions (SCL) after atrial fibrillation (AF) ablation is highly variable, depending on the technology used. Recently, an increased risk for SCL has been described for a novel, nonirrigated ablation tool using multielectrode phased radiofrequency (PVAC). The aim of this prospective study was to evaluate the incidence and long-term follow-up of SCL in patients undergoing robotically assisted pulmonary vein isolation (RA-PVI) as compared with manual PVI. Methods and Results— Circumferential PVI using irrigated radiofrequency current was performed on 70 patients (41 patients with paroxysmal AF, 59%). Fifty patients underwent RA-PVI and 20 patients underwent a manual approach. Cerebral MRI was performed the day before and the day after the ablation procedure; follow-up MRI was performed on 9 of 12 (75%) patients after a follow-up period of 21 months. SCLs were found in 12 of 70 (17%) patients in this study; the incidence of SCLs was similar in patients undergoing RA-PVI as compared with manually ablated patients (n=9, 18% versus n=3, 15%; probability value=1.0). In 1 patient undergoing manual PVI (1%), an SCL with asymptomatic subarachnoid hemorrhage was detected; the bleeding completely resolved within 1 month. Transient ischemic attack occurred in 1 (1%) patient 2 days after manual PVI. After a median follow-up period of 21 months, no residual SCLs were detected. Conclusions— The incidence of SCL using the robotic navigation system was 18% in this study. Incidence and size of SCL appears to be similar after RA-PVI as compared with manual PVI. Repeat MRI showed no residual SCLs at long-term follow-up.

Microembolism and Catheter Ablation I

“…10 Recent reports have described a high prevalence of asymptomatic cerebral lesions after AF ablation procedures observed on diffusion-weighted MRI (DWI) that are presumed to be embolic in origin. [11][12][13][14][15][16] However, the exact mechanism and composition of the embolic material have not been characterized. The present study created an experimental model of left atrial ablation in swine to fully characterize and quantify the production of microbubble and particulate emboli to determine its potential for creation of asymptomatic cerebral ischemic lesions.…”

Evaluation and Reduction of Asymptomatic Cerebral Embolism in Ablation of Atrial Fibrillation, But High Prevalence of Chronic Silent Infarction

“…3,6,7,[15][16][17][18][19][20] Two studies also suggested that the rate of ACE associated with MER circular catheters was significantly higher than the ACE rate associated with irrigated RF catheters. 7,8 These 2 studies used an ACT cutoff of 300 seconds but used interrupted VKA with low-molecular-weight heparin bridging periablation.…”

“…Pre-existing lesions were predominantly found in the frontal and parietal lobes, as demonstrated in this sample patient. There were a median of 8 lesions per subject (interquartile range, [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. spontaneous; 45% were electrical).…”

“…This is higher than, but consistent with, rates of PEL reported in other studies, which have ranged from 12.3% to 58%. 5,6,[15][16][17]20 This shows that even in AF patients with low CHADS 2 risk scores, silent embolic lesions are still prevalent. This high burden of embolism and chronic scar formation caused by chronic AF has been shown to correlate with development of cognitive decline.…”

“…A higher score is "better" with a score of 25 or more indicating near normal or normal cognition. Scores less than this can indicate severe (<10), moderate (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20), and mild (21-24) cognitive impairment. The table below lists the categories of testing as well as samples of the questions and/or tasks requested of the patient.…”