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Hu X, Li W, Ren B, Zeng R. Incidence of silent cerebral events detected by MRI in patients with atrial fibrillation undergoing pulsed field ablation vs thermal ablation: A systematic review and network meta-analysis. Heart Rhythm 2025:S1547-5271(25)02315-X. [PMID: 40221109 DOI: 10.1016/j.hrthm.2025.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2024] [Revised: 04/01/2025] [Accepted: 04/05/2025] [Indexed: 04/14/2025]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and catheter ablation has been demonstrated to achieve superior success rates compared with antiarrhythmic drugs. However, this procedure entails certain risks, including silent cerebral events (SCEs), which may affect cognitive function. This network meta-analysis aimed to determine the global incidence of SCEs in patients with AF undergoing catheter ablation and to compare the incidence across energy sources and catheter types. Our analysis included 86 trials involving 10,456 patients with AF, with a pooled SCE incidence of 19.1%. For pulsed field ablation, the incidence of SCEs was 14.4%; thermal ablation techniques showed rates of 17.7% for radiofrequency ablation, 20.8% for cryoballoon ablation, and 32.7% for laser ablation. No significant differences were found between pulsed field ablation and thermal ablation in SCE incidence. The comparison of SCE incidence between different catheter types revealed variations. The HD Mesh Ablator demonstrated the lowest incidence rate (15.1%), whereas the PVAC catheter had the highest (36.2%). The Farawave catheter had an incidence rate of 18.5% and showed no significant differences compared with most thermal catheters, except for the HD Mesh Ablator (relative risk, 0.15; 95% credible interval, 0.03-0.89). Our findings indicate that a substantial proportion of patients experience SCEs after catheter ablation for AF, with an overall incidence of approximately 19.1% occurring within 1 week (mostly within 72 hours) after ablation. No significant differences were observed in SCE incidence between pulsed field ablation and thermal ablation or between the Farawave catheter and most thermal catheters.
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Affiliation(s)
- Xianjin Hu
- Department of Cardiology, West China Hospital, Sichuan University, China
| | - Wenjie Li
- Department of Cardiology, West China Hospital, Sichuan University, China
| | - Bangjiaxin Ren
- Department of Cardiology, West China Hospital, Sichuan University, China
| | - Rui Zeng
- Department of Cardiology, West China Hospital, Sichuan University, China.
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Zheng T, Kong Y, Wu L, Wu C, Mao W, Zhou X. Silent cerebral lesions after catheter ablation for atrial fibrillation using cryoballoon, hotballoon, laserballoon and radiofrequency catheters: a Bayesian network meta-analysis. Front Cardiovasc Med 2025; 11:1510468. [PMID: 39877018 PMCID: PMC11772368 DOI: 10.3389/fcvm.2024.1510468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2024] [Accepted: 12/31/2024] [Indexed: 01/31/2025] Open
Abstract
Background Catheter ablation (CA) is an effective therapeutic option for patients with symptomatic atrial fibrillation (AF). Previous studies have reported silent cerebral lesions (SCLs) detected by magnetic resonance imaging (MRI) after different CA techniques; however, the results were controversial. Therefore, we performed this network meta-analysis (NMA) to assess the incidence of SCLs after cryoballoon, hotballoon, laserballoon, and radiofrequency ablation (RFA). Methods Databases such as PubMed, Embase, and the Cochrane Library were searched systematically. Both pairwise meta-analysis (PMA) and NMA were conducted. The primary outcome was the incidence of new SCLs on MRI after CA procedures. Results Nine studies were analyzed and 1,057 patients were enrolled. Laserballoon ablation (LBA) had a higher incidence of SCLs than cryoballoon ablation (CBA) [odds ratio [OR] = 1.86, 95% confidence interval [CI] 1.06-3.27, p = 0.032] in the PMA, while no significant difference was detected between the CA techniques according to the NMA. The surface under the cumulative ranking curve (SUCRA) values indicated that CBA may be the best therapeutic option (SUCRA = 81.1%). The NMA results demonstrated similar procedure-related complication rates and mean activated clotting time between CBA (SUCRA = 53.7%, 66.3%), hotballoon ablation (HBA) (SUCRA = 81.5%, 43.6%), LBA (SUCRA = 3.39%, 42.8%) and RFA (SUCRA = 61.3%, 47.3%). LBA therapy required significantly more procedure time than CBA [weighted mean difference (WMD) = 24.36 min, 95% CI 12.51-36.21 min, p = 0.00]. Conclusions CBA treatment had lower incidence of post-procedural SCLs and took less procedure time compared with LBA for patients with AF. The procedure-related complications were comparable between CBA, LBA, HBA and RFA. Systematic Review Registration PROSPERO, identifier (CRD42024511110).
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Affiliation(s)
- Tiantian Zheng
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Youjin Kong
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Li Wu
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Chenxia Wu
- Department of Cardiology, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Key Laboratory of Integrative Chinese and Western Medicine for Diagnosis and Treatment of Circulatory Diseases, Hangzhou, China
| | - Wei Mao
- Department of Cardiology, Affiliated Zhejiang Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Key Laboratory of Integrative Chinese and Western Medicine for Diagnosis and Treatment of Circulatory Diseases, Hangzhou, China
| | - Xinbin Zhou
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
- Zhejiang Key Laboratory of Integrative Chinese and Western Medicine for Diagnosis and Treatment of Circulatory Diseases, Hangzhou, China
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Patel C, Gerstenfeld EP, Gupta SK, Winterfield J, Woods C, Natale A, Schneider CW, Achyutha AB, Holland SK, Richards E, Albrecht EM, Lehmann JW, Mansour M, Reddy VY. Comparison of cerebral safety after atrial fibrillation using pulsed field and thermal ablation: Results of the neurological assessment subgroup in the ADVENT trial. Heart Rhythm 2024; 21:2103-2109. [PMID: 38823667 DOI: 10.1016/j.hrthm.2024.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) ablation carries the risk of silent cerebral event (SCE) and silent cerebral lesion (SCL). Although "silent," these may have long-term clinical implications and are challenging to study as postprocedural magnetic resonance imaging (MRI) is not standard of care. OBJECTIVE The neurological assessment subgroup (NAS) of ADVENT compared cerebral effects of pulsed field ablation (PFA) with standard-of-care thermal ablation. METHODS The NAS included consecutive randomized PFA and thermal ablation patients who received postprocedural brain MRI 12-48 hours after ablation. Patients with apparent SCE or SCL findings underwent a modified Rankin scale assessment. MRI images were subsequently reviewed by a blinded brain imaging core laboratory. RESULTS In total, 77 patients with paroxysmal AF were enrolled at 6 centers; 71 had analyzable scans (34 PFA; 37 thermal ablation). Through individual center review, 6 PFA and 4 thermal scans were identified as SCE/SCL positive, of which 3 PFA and 0 thermal SCE/SCL findings were confirmed by a blinded core laboratory. MRI findings revealed 1 patient with 2- to 4-mm SCEs, 1 patient with a 3-mm SCE, and 1 patient with 2 SCLs (5.5 mm and 11 mm). All modified Rankin scale and National Institutes of Health Stroke Scale scores were 0 before discharge and at 90-day follow-up. There were only 2 neurological safety events (1 transient ischemic attack [PFA] and 1 stroke [thermal ablation]) in the ADVENT study, neither of which was part of the NAS. CONCLUSION The ADVENT trial provides the first prospective, randomized data on the cerebral impact of PFA and thermal ablation of AF. Incidence of SCE/SCL after ablation in the NAS was low.
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Affiliation(s)
| | | | - Sanjaya K Gupta
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | | | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York
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Koshikawa M, Harada M, Nomura Y, Nishimura A, Motoike Y, Watanabe E, Ozaki Y, Izawa H. Impact of different energy sources on coagulation biomarkers and silent cerebral events in balloon-based ablation for atrial fibrillation. Heart Rhythm O2 2024; 5:520-528. [PMID: 39263611 PMCID: PMC11385400 DOI: 10.1016/j.hroo.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2024] Open
Abstract
Background Different energy sources of balloon-based ablation for pulmonary vein isolation cause different kinds of endothelial damage and coagulation responses associated with thromboembolic risk. Objectives The study sought to compare the impact of different balloon-based ablation, cryoballoon ablation (CBA) and laser balloon ablation (LBA), on coagulation/fibrinolysis biomarkers and silent cerebral events (SCEs) in paroxysmal atrial fibrillation. Methods Paroxysmal atrial fibrillation patients who underwent pulmonary vein isolation using either CBA (n = 52) or LBA (n = 53) without radiofrequency touch-up ablation were eligible. Time course (day 0 [before ablation], day 1, day 2, and day 28) of myocardial enzymes and inflammatory and coagulation/fibrinolysis biomarkers was evaluated during the perioperative period. Brain magnetic resonance imaging was performed within 2 days after the procedure to evaluate SCEs. Results There was no difference in patient characteristics between CBA and LBA.CBA had greater myocardial injury (troponin I and creatine kinase-MB) and lower inflammatory reaction (white blood cell count and neutrophil/lymphocyte ratio) than LBA. The coagulation biomarkers maximally increased by day 2 and then decreased in both groups. In day 28, the serum prothrombin fragment 1+2 and D-dimer levels in LBA were significantly higher than the values in CBA. The fibrinolysis biomarker (plasmin-α2 plasmin inhibitor complex) did not increase after the procedure in either group. The incidence of SCEs was comparable between CBA and LBA (11% vs 15%; P = .591). No thromboembolic event was observed. Conclusion CBA and LBA had different effects on myocardial injury, inflammatory reaction, and coagulation activity but did not affect the incidence of thromboembolic events. LBA had significantly higher coagulation activity in day 28 and may require more careful postprocedural anticoagulation than CBA.
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Affiliation(s)
| | - Masahide Harada
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Yoshihiro Nomura
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Asuka Nishimura
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Yuji Motoike
- Department of Cardiology, Fujita Health University, Toyoake, Japan
| | - Eiichi Watanabe
- Department of Cardiology, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Yukio Ozaki
- Department of Cardiology, Okazaki Medical Center, Fujita Health University, Okazaki, Japan
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University, Toyoake, Japan
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Saglietto A, Bertello E, Barra M, Ferraro I, Rovera C, Orzan F, De Ferrari GM, Anselmino M. MRI pattern characterization of cerebral cardioembolic lesions following atrial fibrillation ablation. Front Cardiovasc Med 2024; 11:1327567. [PMID: 38327489 PMCID: PMC10847299 DOI: 10.3389/fcvm.2024.1327567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024] Open
Abstract
Background Recognizing etiology is essential for treatment and secondary prevention of cerebral ischemic events. A magnetic resonance imaging (MRI) pattern suggestive of an embolic etiology has been described but, to date, there are no uniformly accepted criteria. Aim The purpose of the study is to describe MRI features of ischemic cerebral lesions occurring after transcatheter ablation of atrial fibrillation (AF). Methods A systematic review and meta-analysis of studies performing brain imaging investigations before and after AF transcatheter ablation was performed. The incidence of cerebral ischemic lesions after AF transcatheter ablation was the primary endpoint. The co-primary endpoints were the prevalence of the different neuroimaging features regarding the embolic cerebral ischemic lesions. Results A total of 25 studies, encompassing 3,304 patients, were included in the final analysis. The incidence of ischemic cerebral lesions following AF transcatheter ablation was 17.2% [95% confidence interval (CI) 12.2%-23.8%], of which a minimal fraction was symptomatic [0.60% (95% CI 0.09%-3.9%)]. Only 1.6% of the lesions (95% CI 0.9%-3.0%) had a diameter >10 mm, and in 20.5% of the cases the lesions were multiple (95% CI 17.1%-24.4%). Brain lesions were equally distributed across the two hemispheres and the different lobes; cortical location was more frequent [64.0% (95% CI 42.9%-80.8%)] while the middle cerebral artery territory was the most involved 37.0% (95% CI 27.3-48.0). Conclusions The prevailing MRI pattern comprises a predominance of small (<10 mm) cortical lesions, more prevalent in the territory of the middle cerebral artery.
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Affiliation(s)
- Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Eleonora Bertello
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marina Barra
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ilenia Ferraro
- Division of Cardiology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Chiara Rovera
- Department of Cardiology, Civic Hospital of Chivasso, Chivasso, Italy
| | - Fulvio Orzan
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
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Sun X, Zhao S, Yu S, Cui K. Cryoballoon vs. laser balloon ablation for atrial fibrillation: a meta-analysis. Front Cardiovasc Med 2023; 10:1278635. [PMID: 38169911 PMCID: PMC10761002 DOI: 10.3389/fcvm.2023.1278635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024] Open
Abstract
Background Cryoballoon ablation (CBA) and laser balloon ablation (LBA) are two innovative ways for the treatment of atrial fibrillation (AF). This study aimed to evaluate the efficacy and safety of cryoballoon ablation and laser balloon ablation in patients with AF. Methods We searched Pubmed, Embase, Ovid, Web of Science and other databases for comparative trials comparing CB and LB ablation in the treatment of AF, from establishment of database to August, 2023. Results A total of 13 studies and 3,582 patients were included (CBA, n = 2,308; LBA, n = 1,274). There was no difference between CBA and LBA in acute PVI rate per vein, 12-months recurrence rate of AF, 12-months recurrence rate of atrial arrhythmia, occurrence rate of pericardial tamponade, occurrence rate of inguinal complications. LBA presented a lower acute PVI rate per patients (CBA 97.0% vs. LBA 93.4%, RR = 1.04, 95%CI: 1.01-1.07). Transient nerve palsy was more likely to occur after CBA (CBA 2.7% vs. LBA 0.7%, RR = 4.25, 95%CI: 2.06-8.76). However, the occurrence of persistent nerve palsy between CBA and LBA groups were similar (CB 1.4% vs. LB 1.0%, RR = 1.09, 95%CI: 0.55-2.14). In terms of procedural duration, the procedural time of CBA was shorter than that of LBA (WMD = -26.58, 95%CI: -36.71-16.46). Conclusions Compared with LBA, CBA had a shorter procedural duration. There was a higher incidence of transient but not persistent phrenic nerve palsy after CBA. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272607 Identifier (CRD42021272607).
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Affiliation(s)
- Xiaochi Sun
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shenyu Zhao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Simin Yu
- West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Fink T, Sciacca V, Neven K, Didenko M, Sommer P, Sohns C. Pulsed field ablation for atrial fibrillation - Lessons from magnetic resonance imaging. Pacing Clin Electrophysiol 2023; 46:1586-1594. [PMID: 37943015 DOI: 10.1111/pace.14864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/19/2023] [Accepted: 10/21/2023] [Indexed: 11/10/2023]
Abstract
Pulsed field ablation (PFA) is a promising technology for the treatment of atrial fibrillation (AF). Due to its unique tissue selectivity, PFA potentially bears superior characteristics as compared to established thermal energy sources in AF ablation procedures. Cardiovascular magnetic resonance imaging (CMR) using late gadolinium enhancement (LGE) is an established tool in the analysis of myocardial fibrosis representing atrial cardiomyopathy as well as ablation-induced atrial scar formation following catheter ablation with thermal energy. Mechanisms of atrial lesion formation differ between thermal ablation and electroporation and its impact on results of CMR imaging are not fully understood until now. In this review article, the potential of CMR imaging for PFA lesion assessment and available data are discussed. Further, additional needs to adopt imaging approaches to the cellular mechanisms of electroporation are considered.
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Affiliation(s)
- Thomas Fink
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Vanessa Sciacca
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Dept. of Medicine, Witten/Herdecke University, Witten, Germany
| | - Maxim Didenko
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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Zhang J, Li S, Sang C, Ma C. Atrial fibrillation catheter ablation associated silent cerebral emboli: A narrative review. Pacing Clin Electrophysiol 2023; 46:1124-1133. [PMID: 37578003 DOI: 10.1111/pace.14779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 08/15/2023]
Abstract
The incidence of silent cerebral emboli (SCE) associated with atrial fibrillation catheter ablation (AFCA) is much higher than that of stroke/transient ischemic attack (TIA). Interventional electrophysiologists have been increasingly alerted to asymptomatic cerebral infarction over the years. Plentiful studies revealed that diagnostic definitions, detection modalities, energy sources, ablation strategies, perioperative anticoagulation regimens, and patient-related factors were associated with the risk of AFCA-associated SCE. Studies related to non-interventional procedures found that SCE may prompt stroke, cognitive decline, and dementia later in life, suggesting a possible role of AFCA-associated SCE in the cognitive function of patients with AF. However, there is no consistent evidence for this view to date. Given that the majority of patients with AF being elderly and the increased risk of cognitive impairment in AF itself, efforts should be made to minimize the occurrence of AFCA-associated SCE.
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Affiliation(s)
- Jingrui Zhang
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Songnan Li
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Caihua Sang
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changsheng Ma
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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Wu C, Hu L, Kong Y, Zhao B, Mao W, Zhou X. Bayesian network meta-analysis comparing hot balloon, laser balloon and cryoballoon ablation as initial therapies for atrial fibrillation. Front Cardiovasc Med 2023; 10:1184467. [PMID: 37560114 PMCID: PMC10407100 DOI: 10.3389/fcvm.2023.1184467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/10/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Balloon-based catheter ablation (CA) technologies, including hot balloon ablation (HBA), laser balloon ablation (LBA) and cryoballoon ablation (CBA) have been introduced in recent years as alternatives to conventional radiofrequency ablation therapy for atrial fibrillation (AF). However, the results remain controversial concerning the optimal approach. Thus, we conducted a network meta-analysis (NMA) to comprehensively evaluate the efficacy and safety of HBA, LBA and CBA. METHODS Clinical trials comparing the efficacy and safety of HBA, LBA and CBA were identified through a systematic search up to October 2022. The primary outcomes of interest were the recurrence of AF and procedure-related complications. RESULTS Twenty clinical trials with a total of 1,995 patients were included in the meta-analysis. The NMA results demonstrated that HBA, LBA and CBA had comparable AF recurrence rates (HBA vs. CBA: odds ratio OR = 0.88, 95% credible interval CrI: 0.56-1.4; LBA vs. CBA: OR = 1.1, 95% CrI: 0.75-1.5; LBA vs. HBA: OR = 1.2, 95% CrI: 0.70-2.0) and procedure-related complications (HBA vs. CBA: OR = 0.93, 95% CrI: 0.46-2.3; LBA vs. CBA: OR = 1.1, 95% CrI: 0.63-2.1; LBA vs. HBA: OR = 1.2, 95% CrI: 0.44-2.8). The surface under the cumulative ranking curve (SUCRA) suggested that HBA may be the optimal approach concerning the primary outcomes (SUCRA = 74.4%; 61.1%, respectively). However, HBA (40.1%) had a significantly higher incidence of touch-up ablation (TUA) than LBA (8.5%, OR = 2.8, 95% CrI: 1.1-7.1) and CBA (11.9%, OR = 3.7, 95% CrI: 1.9-7.5). LBA required more procedure time than CBA [mean difference (MD = 32.0 min, 95% CrI: 19.0-45.0 min)] and HBA (MD = 26.0 min, 95% CrI: 5.6-45.0 min), but less fluoroscopy time than HBA (MD = -9.4 min, 95% CrI: -17.0--2.4 min). CONCLUSIONS HBA, LBA and CBA had comparable efficacy and safety as initial treatments for AF. HBA ranked highest in the primary outcomes, but at the cost of a higher incidence of TUA and longer fluoroscopy time. SYSTEMATIC REVIEW REGISTRATION www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022381954, identifier: CRD42022381954.
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Affiliation(s)
- Chenxia Wu
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Luoxia Hu
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Youjin Kong
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Bowen Zhao
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Wei Mao
- Department of Cardiology, Zhejiang Hospital, Hangzhou, China
- Key Laboratory of Integrative Chinese and Western Medicine for the Diagnosis and Treatment of Circulatory Diseases of Zhejiang Province, Hangzhou, China
| | - Xinbin Zhou
- Department of Cardiology, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
- Key Laboratory of Integrative Chinese and Western Medicine for the Diagnosis and Treatment of Circulatory Diseases of Zhejiang Province, Hangzhou, China
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Calvert P, Kollias G, Pürerfellner H, Narasimhan C, Osorio J, Lip GYH, Gupta D. Silent cerebral lesions following catheter ablation for atrial fibrillation: a state-of-the-art review. Europace 2023; 25:euad151. [PMID: 37306314 PMCID: PMC10259069 DOI: 10.1093/europace/euad151] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/25/2023] [Indexed: 06/13/2023] Open
Abstract
Atrial fibrillation is associated with neurocognitive comorbidities such as stroke and dementia. Evidence suggests that rhythm control-especially if implemented early-may reduce the risk of cognitive decline. Catheter ablation is highly efficacious for restoring sinus rhythm in the setting of atrial fibrillation; however, ablation within the left atrium has been shown to result in MRI-detected silent cerebral lesions. In this state-of-the-art review article, we discuss the balance of risk between left atrial ablation and rhythm control. We highlight suggestions to lower the risk, as well as the evidence behind newer forms of ablation such as very high power short duration radiofrequency ablation and pulsed field ablation.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
| | | | | | - Calambur Narasimhan
- Department of Cardiac Electrophysiology, AIG Hospitals, 1-66/AIG/2 to 5, Mindspace Road, Gachibowli Hyderabad, Telangana 500032, India
| | - Jose Osorio
- Grandview Medical Center, Arrhythmia Institute at Grandview, 3686 Grandview Parkway Suite 720, Birmingham, AL 35243, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
- Danish Centre for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
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Innovations in atrial fibrillation ablation. J Interv Card Electrophysiol 2022; 66:737-756. [PMID: 35411440 DOI: 10.1007/s10840-022-01215-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Catheter-based ablation to perform pulmonary vein isolation (PVI) has established itself as a mainstay in the rhythm control strategy of atrial fibrillation. This review article aims to provide an overview of recent advances in atrial fibrillation ablation technology. METHODS We reviewed the available literature and clinical trials of innovations in atrial fibrillation ablation technologies including ablation catheter designs, alternative energy sources, esophageal protection methods, electroanatomical mapping, and novel ablation targets. RESULTS Innovative radiofrequency (RF) catheter designs maximize energy delivery while avoiding overheating associated with conventional catheters. Single-shot balloon catheters in the form of cryoballoons, radiofrequency, and laser balloons have proven effective at producing pulmonary vein isolation and improving procedural efficiency and reproducibility. Pulsed field ablation (PFA) is a highly anticipated novel nonthermal energy source under development, which demonstrates selective ablation of the myocardium, producing durable lesions while also minimizing collateral damage. Innovative devices for esophageal protection including esophageal deviation and cooling devices have been developed to reduce esophageal complications. Improved electroanatomical mapping systems are being developed to help identify additional non-pulmonary triggers, which may benefit from ablation, especially with persistent atrial fibrillation. Lastly, the vein of Marshall alcohol ablation has been recently studied as an adjunct therapy for improving outcomes with catheter ablation for persistent atrial fibrillation. CONCLUSIONS Numerous advances have been made in the field of atrial fibrillation ablation in the past decade. While further long-term data is still needed for these novel technologies, they show potential to improve procedural efficacy and safety.
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Zheng J, Wang M, Tang QF, Xue F, Li KL, Dang SP, Liu XY, Zhao XX, Zhang CY, Yu ZM, Han B, Jiang TB, Yao Y, Wang RX. Atrial Fibrillation Ablation Using Robotic Magnetic Navigation Reduces the Incidence of Silent Cerebral Embolism. Front Cardiovasc Med 2021; 8:777355. [PMID: 34926624 PMCID: PMC8671737 DOI: 10.3389/fcvm.2021.777355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/02/2021] [Indexed: 11/18/2022] Open
Abstract
Background: The incidence of silent cerebral embolisms (SCEs) has been documented after pulmonary vein isolation using different ablation technologies; however, it is unreported in patients undergoing with atrial fibrillation (AF) ablation using Robotic Magnetic Navigation (RMN). The purpose of this prospective study was to investigate the incidence, risk predictors and probable mechanisms of SCEs in patients with AF ablation and the potential impact of RMN on SCE rates. Methods and Results: We performed a prospective study of 166 patients with paroxysmal or persistent AF who underwent pulmonary vein isolation. Patients were divided into RMN group (n = 104) and manual control (MC) group (n = 62), and analyzed for their demographic, medical, echocardiographic, and risk predictors of SCEs. All patients underwent cerebral magnetic resonance imaging within 48 h before and after the ablation procedure to assess cerebral embolism. The incidence and potential risk factors of SCEs were compared between the two groups. There were 26 total cases of SCEs in this study, including 6 cases in the RMN group and 20 cases in the MC group. The incidences of SCEs in the RMN group and the MC group were 5.77 and 32.26%, respectively (X2 = 20.63 P < 0.05). Univariate logistic regression analysis demonstrated that ablation technology, CHA2DS2-VASc score, history of cerebrovascular accident/transient ischemic attack, and low ejection fraction were significantly associated with SCEs, and multivariate logistic regression analysis showed that MC ablation was the only independent risk factor of SCEs after an AF ablation procedure. Conclusions: Ablation technology, CHA2DS2-VASc score, history of cerebrovascular accident/transient ischemic attack, and low ejection fraction are associated with SCEs. However, ablation technology is the only independent risk factor of SCEs and RMN can significantly reduce the incidence of SCEs resulting from AF ablation. Clinical Trial Registration: ChiCTR2100046505.
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Affiliation(s)
- Jie Zheng
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Meng Wang
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Qun-Feng Tang
- Department of Radiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Feng Xue
- Department of Cardiology, The First Hospital Affiliated to Soochow University, Suzhou, China
| | - Ku-Lin Li
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Shi-Peng Dang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Xiao-Yu Liu
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Xiao-Xi Zhao
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Chang-Ying Zhang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Zhi-Ming Yu
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Bing Han
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Ting-Bo Jiang
- Department of Cardiology, The First Hospital Affiliated to Soochow University, Suzhou, China
| | - Yan Yao
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences - Peking Union Medical College, Beijing, China
| | - Ru-Xing Wang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
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Hyperintense Brain Lesions in Asymptomatic Low Risk Patients with Paroxysmal Atrial Fibrillation Undergoing Radiofrequency Pulmonary Vein Isolation. J Clin Med 2021; 10:jcm10040565. [PMID: 33546182 PMCID: PMC7913160 DOI: 10.3390/jcm10040565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim was to determine the occurrence, consequences and risk factors for brain white matter hyperintensities (WMH) assessed in magnetic resonance imaging (MRI) in low-risk patients with paroxysmal atrial fibrillation (AF) undergoing radiofrequency pulmonary vein isolation (PVI-RF). METHODS 74 patients with AF (median 58.5 years (IQR 50-63), 45 male) were included. Before and after a minimum of 6 months after PVI-RF, a brain MRI and a mini-mental state examination (MMSE) were performed. RESULTS Baseline WMH lesions were found in 55 (74.3%) patients and in 48 from 62 (77.4%) patients after PVI-RF. The WMH lesions were more frequent among older patients, with a higher CHA2DS2-Vasc (C-Congestive heart failure/LV dysfunction, H-Hypertension, A-Age, D-Diabetes mellitus, S-Stroke, V-Vascular Disease, Sc-Sex category). Factors affecting the severity of the WMH were: older age, the co-existence of the PFO and coronary artery disease (CAD). After a follow-up period, the factors predisposing to brain WMH lesions occurrence (age, higher BMI and CHA2DS2-Vasc score) and to the more advanced changes (age, higher CHA2DS2-Vasc score, CAD, PFO) were obtained. CONCLUSIONS The presence and severity of cerebral microembolism are associated with age, higher CHA2DS2-Vasc score and the coexistence of PFO and CAD. PVI-RF procedure and its efficacy does not influence on MRI lesions. In this population, cerebral microembolism is not related to cognitive impairment.
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Keeping it Simple: Balloon Devices for Atrial Fibrillation Ablation Therapy. JACC Clin Electrophysiol 2020; 6:1577-1596. [PMID: 33213820 DOI: 10.1016/j.jacep.2020.08.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 11/22/2022]
Abstract
Atrial fibrillation is a common disease of increasing prevalence. Catheter ablation has evolved into an established therapeutic option that mainly aims to electrically isolate the pulmonary veins from atrial myocardium. The traditional method comprises point-by-point radiofrequency current ablation guided by electroanatomical mapping and has proven to be effective and safe in experienced hands. However, this approach is technically highly demanding and associated with a long learning curve, limiting its widespread utilization. To address these shortcomings, simplified ablation tools for pulmonary vein isolation are needed. In this context, balloon devices promise to ease the procedure by approaching the entire orifice of a targeted pulmonary vein in a single maneuver. This requires less catheter manipulation in the left atrium and often allows ablation of a large volume of tissue with a single application of ablative energy. Two balloon devices-one using cryoenergy, the other laser energy-have already been established in clinical routine and have demonstrated noninferiority when compared with radiofrequency ablation in large randomized trials. More balloon devices are on the verge of being introduced into clinical practice and bear the potential to expand the interventional electrophysiologist's armamentarium when treating atrial fibrillation. The authors review the use of the established balloon devices available for atrial fibrillation ablation and provide a detailed outlook on upcoming balloon technologies, including 3 different balloons utilizing radiofrequency energy as well as a novel cryoballoon.
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Okishige K, Shigeta T, Nakamura RA, Hirao T, Yoshida H, Oda A, Yamauchi Y, Sasano T, Hirao K. Experimental Study with Regard to the Effects of Energy Titration of the Laserballoon on the Lesion Creation Using Porcine Myocardium. Int Heart J 2020; 61:121-127. [DOI: 10.1536/ihj.19-286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital
| | | | | | | | | | - Atsuhito Oda
- Heart Center, Japan Red Cross Yokohama City Bay Hospital
| | | | - Tetsuo Sasano
- Arrhythmia Center, Tokyo Medical and Dental University
| | - Kenzo Hirao
- Arrhythmia Center, Tokyo Medical and Dental University
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Yanagisawa S, Inden Y, Fujii A, Sakamoto Y, Tomomatsu T, Mamiya K, Okamoto H, Shibata R, Murohara T. Prothrombotic Responses After Catheter Ablation for Atrial Fibrillation During Uninterrupted Oral Anticoagulant Agent Administration. JACC Clin Electrophysiol 2019; 5:1418-1427. [PMID: 31857041 DOI: 10.1016/j.jacep.2019.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the extent of changes in prothrombotic responses after catheter ablation for atrial fibrillation (AF) under uninterrupted oral anticoagulant agent (OAC) administration. BACKGROUND Catheter ablation for AF has a potential risk for prothrombotic activation and silent thromboembolic events. METHODS A total of 814 patients (n = 172 [warfarin], n = 153 [dabigatran], n = 134 [rivaroxaban], and n = 301 [apixaban] patients undergoing AF ablation and a control group of 54 patients undergoing non-AF ablation) were included. Uninterrupted OACs were administered during the procedure in patients with AF. Blood samples were collected the day before and 3 days after the procedure. RESULTS At baseline, D-dimer levels were within normal limits (≤1.0 μg/ml) in more than 90% of the patients in all groups. However, after 3 days, this proportion decreased to 67%, 73%, 59%, 68%, and 65% in the warfarin, dabigatran, rivaroxaban, apixaban, and control groups, respectively (p = 0.180). Changes in prothrombin fragment 1+2 levels differed (p < 0.001), whereas fibrin monomer complex levels 3 days after ablation at a trough were equivalent within normal ranges among the groups (p = 0.146). Multivariate analysis revealed that age, CHA2DS2-VASc score, first session, and radiofrequency ablation were independent predictors of increased D-dimer levels after the procedure. Various changes in prothrombotic markers were observed between the warfarin and direct OAC groups after propensity score matching analyses. CONCLUSIONS The coagulation cascade was activated after catheter ablation for AF under uninterrupted OAC administration. The changes in various prothrombotic markers differed among the OAC groups.
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Affiliation(s)
- Satoshi Yanagisawa
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Aya Fujii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Sakamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshiro Tomomatsu
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keita Mamiya
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroya Okamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Rei Shibata
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Nakamura K, Sasaki T, Take Y, Minami K, Inoue M, Kishi S, Yoshimura S, Sasaki W, Okazaki Y, Motoda H, Niijima K, Miki Y, Goto K, Yamashita E, Koyama K, Funabashi N, Naito S. Impact of the type of electroanatomic mapping system on the incidence of cerebral embolism after radiofrequency catheter ablation of left atrial tachycardias. Heart Rhythm 2019; 17:250-257. [PMID: 31518721 DOI: 10.1016/j.hrthm.2019.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Left atrial tachycardias (ATs) often occur after left atrial ablation. The incidence of symptomatic and silent cerebral embolism after radiofrequency catheter ablation of left ATs and the impact of the type of 3-dimensional electroanatomic mapping (3D-EAM) system on the incidence of cerebral embolism remain unclear. OBJECTIVES This study aimed to investigate the incidence of cerebral embolism after a 3D-EAM system-guided left AT ablation procedure and compare that between the different 3D-EAM systems. METHODS We prospectively enrolled 59 patients who underwent left AT ablation and brain magnetic resonance imaging after the procedure: 30 were guided by the Rhythmia system (Boston Scientific, Marlborough, MA) and 29 by the CARTO system (Biosense Webster, Diamond Bar, CA) (groups R and C, respectively). RESULTS One transient ischemic attack occurred in group R, and no symptomatic embolism occurred in group C. Silent cerebral ischemic lesions (SCILs) were observed in 35 patients (59.3%), and group R had a significantly higher incidence of SCILs than did group C (86.2% vs 33.3%; P < .001). In multivariate analysis, group R and left atrial linear ablation were independent positive predictors of SCILs (odds ratio 12.822 and 8.668; P = .001 and P = .005). The incidence of bleeding complications was comparable between groups R and C (0% vs 3.3%; P = .508). CONCLUSION Group R exhibited a higher incidence of postablation cerebral embolism than did group C. The use of the high-resolution 3D-EAM system with a mini-basket catheter to guide radiofrequency ablation of left atrial macroreentrant tachycardias may markedly increase the risk of silent cerebral embolism. The present results require further validation in a randomized study.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan.
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Hiroyuki Motoda
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Katsura Niijima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chuo-ku, Chiba City, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
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Osaka Y, Ono Y, Tao S, Goto K, Miyazaki T, Suzuki A, Kurihara K, Otomo K, Hirao K. Feasibility and safety of uninterrupted apixaban in patients undergoing radiofrequency ablation for atrial fibrillation. J Interv Card Electrophysiol 2019; 58:35-41. [DOI: 10.1007/s10840-019-00563-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
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Nakamura K, Sasaki T, Take Y, Okazaki Y, Inoue M, Motoda H, Miki Y, Niijima K, Yamashita E, Koyama K, Funabashi N, Naito S. Postablation cerebral embolisms in balloon-based atrial fibrillation ablation with periprocedural direct oral anticoagulants: A comparison between cryoballoon and HotBalloon ablation. J Cardiovasc Electrophysiol 2018; 30:39-46. [PMID: 30288849 DOI: 10.1111/jce.13762] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/19/2018] [Accepted: 09/25/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION This prospective observational study aimed to investigate the incidence of symptomatic and silent cerebral embolisms after balloon-based ablation of atrial fibrillation (AF) in patients receiving periprocedural anticoagulation with direct oral anticoagulants (DOACs), and compare that between cryoballoon and HotBalloon ablation (CBA and HBA). METHODS AND RESULTS We enrolled 123 consecutive AF patients who underwent a balloon-based pulmonary vein isolation (PVI) and brain magnetic resonance (MR) imaging after the ablation procedure (CBA, n = 65; HBA, n = 58). The DOACs were continued in 62 patients throughout the periprocedural period and discontinued in 61 on the procedural day. Intravenous heparin was infused to maintain an activated clotting time of 300 to 400 seconds during the procedure. No symptomatic embolisms occurred in this series. Silent cerebral ischemic lesions (SCILs) were observed on MR imaging in 22 patients (17.9%), and the incidence of SCILs did not significantly differ between the CBA and HBA groups (21.5 vs 13.8%; P = 0.263). According to a multivariate logistic regression analysis, an older age was an independent positive predictor of SCILs (odds ratio, 1.062; 95% CI, 1.001-1.126; P = 0.046), but neither the balloon catheter type nor periprocedural continuation or discontinuation of the DOACs were significant predictors. The incidence of major and minor bleeding complications was comparable between the CBA and HBA groups (1.5 vs 0%, P = 0.528; 7.7 vs 5.2%, P = 0.424). CONCLUSIONS Both CBA and HBA of AF revealed a similar incidence of postablation cerebral embolisms. Elderly patients may be at a risk of SCILs after a balloon-based PVI with periprocedural DOAC treatment.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Hiroyuki Motoda
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Katsura Niijima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
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Comparison of efficacy and safety of laser balloon and cryoballoon ablation for atrial fibrillation—a meta-analysis. J Interv Card Electrophysiol 2018; 54:237-245. [DOI: 10.1007/s10840-018-0474-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/11/2018] [Indexed: 11/27/2022]
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Asymptomatic Cerebral Infarction During Catheter Ablation for Atrial Fibrillation: Comparing Uninterrupted Rivaroxaban and Warfarin (ASCERTAIN). JACC Clin Electrophysiol 2018; 4:1598-1609. [PMID: 30573125 DOI: 10.1016/j.jacep.2018.08.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 08/08/2018] [Accepted: 08/13/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This randomized study compared uninterrupted rivaroxaban therapy with warfarin therapy as prophylaxis against catheter ablation (CA)-induced asymptomatic cerebral infarction (ACI) and identified the risk factors of rivaroxaban. BACKGROUND The reported incidence of ACI during CA for atrial fibrillation (AF) remains at 10% to 30%, and periprocedural oral anticoagulation could affect this incidence. METHODS Patients with nonvalvular AF undergoing radiofrequency CA were randomly assigned to receive either uninterrupted rivaroxaban or warfarin as periprocedural anticoagulation therapy. CA was performed after at least 1 month of adequate anticoagulation. Cerebral magnetic resonance imaging (MRI) was performed within 2 weeks before and 1 day after CA to detect ACI. RESULTS A total 132 patients were enrolled; 127 (median: 60.0 years of age; 83.5% males; 64.6% incidence of paroxysmal AF) complied with the study protocol and were analyzed; 64 patients received rivaroxaban, and 63 patients received warfarin. The rates of CA-induced ACI in the rivaroxaban group (15.6% [10 of 64 patients]) were similar to those in the warfarin group (15.9% [10 of 63 patients]; p = 1.000). No thromboembolic events developed; no differences in major or nonmajor bleeding rates were observed between the 2 drug groups (3.1% vs. 1.6%, respectively, or 18.8% vs. 19.0%, respectively). Multiple regression analysis indicated that the presence of deep and subcortical white matter hyperintensity (p = 0.002; odds ratio [OR]: 5.323) and the frequency of cardioversions (p = 0.016; OR: 1.250) were associated with the incidence of ACI. CONCLUSIONS No notable differences were found between the incidence of CA-induced ACI in the rivaroxaban group and that in the warfarin group in this randomized study.
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Acibuca A, Vurgun VK, Gerede DM, Altin AT, Gul IS, Candemir B, Isikay Togay C, Kilickap M, Akyurek O. Serum neuron-specific enolase, a marker of neuronal injury, increases after catheter ablation of atrial fibrillation. J Int Med Res 2018; 46:4518-4526. [PMID: 30185093 PMCID: PMC6259406 DOI: 10.1177/0300060518767768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Objective Catheter ablation of atrial fibrillation (AF) can lead to thromboembolic complications, especially stroke. We measured the periprocedural serum neuron-specific enolase (NSE) level, which is a biomarker of neuronal injury, after ablation of AF. Methods Forty-three patients with paroxysmal AF were prospectively enrolled before radiofrequency ablation. A neurological examination was performed before and after the procedure. The serum NSE level was determined before and at the end of the procedure and at 2, 24, and 48 h after the procedure. Results No patients developed new neurological deficits. However, the median (interquartile range) NSE level increased after ablation from 6.7 (3.87) ng/mL at baseline to 11.48 (5.3) ng/mL at 24 h postoperatively. The NSE level exceed the upper reference limit of normal (17 ng/mL) in 14 patients (33%), and these patients were found to have a larger left atrium. Conclusions Serum NSE increased in most of the patients undergoing ablation for AF, and it exceeded the normal limit in one-third of the patients. Although NSE is a biomarker of neuronal injury, the clinical importance of this increase after AF ablation and its relationship with the left atrial diameter should be evaluated in a longitudinal study.
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Affiliation(s)
- Aynur Acibuca
- 1 Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Veysel Kutay Vurgun
- 1 Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Demet Menekse Gerede
- 1 Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Ali Timucin Altin
- 1 Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Inci Sule Gul
- 2 Department of Neurology, Ankara University School of Medicine, Ankara, Turkey
| | - Basar Candemir
- 1 Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Canan Isikay Togay
- 2 Department of Neurology, Ankara University School of Medicine, Ankara, Turkey
| | - Mustafa Kilickap
- 1 Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Omer Akyurek
- 1 Department of Cardiology, Ankara University School of Medicine, Ankara, Turkey
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Eichenlaub M, Pfeufer A, Behrens L, Klauss V, Roettinger M, Brodherr T, Lewalter T. REduction of THRomboembolic EVents during Ablation using the laserballoon: The RETHREVA registry. J Cardiovasc Electrophysiol 2018; 29:365-374. [PMID: 29315961 DOI: 10.1111/jce.13416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 10/25/2017] [Accepted: 12/06/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Cerebral events (CEs), including silent (SCEs), are a known complication of left atrial catheter ablation (LACA) in patients with atrial fibrillation. The aim of this prospective registry was to gain more information about CEs during laserballoon LACA and to reduce the risk of their occurrence. METHODS AND RESULTS We enrolled 74 patients (age 61 ± 11 years; 74% male; CHA2 DS2 -VASc 1.9 ± 1.4). Cerebral MRI (1.5 Tesla) was performed to detect CEs. ASPItest identified aspirin-resistant patients (ARPs). All bleeding complications were recorded. Due to an initial high CE rate, we evolved our clinical procedure step-by-step arriving at an optimized protocol: -Group 1: heparin after single transseptal puncture (TP), activated clotting time (ACT) > 300 seconds (CE: 64.3%). -Group 2: heparin after double TP, ACT > 300 seconds; 2a without (CE: 45.5%, RRR: -29.2%) and 2b with additional intravenous aspirin (CE: 36.4%, RRR: -43.4%; excluding ARP: 30%, RRR: -53.3%). -Group 3: heparin before double TP, ACT > 350 seconds; 3a without (CE: 54.5%, RRR: -15.2%) and 3b with aspirin (CE: 18.5%, RRR: -71.2%; excluding ARP: 8.7%, RRR: -86.5%). Larger LA diameter > 44 mm (OR: 1.149, P = 0.005) and no aspirin use (OR: 4.308, P = 0.008) were CE risk factors in multivariate logistic regression. In those patients receiving aspirin, aspirin resistance (OR: 22.4, P = 0.011) was an exceptionally strong risk factor. CONCLUSION These data support the use of intravenous aspirin including monitoring of aspirin resistance in addition to ACT-guided heparin. An optimized protocol of heparin before TP, double TP, and intravenous aspirin in non-ARP resulted in a significantly lowered CE incidence and severity.
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Affiliation(s)
- Martin Eichenlaub
- Isar Heart Center, Munich, Germany.,Peter Osypka Heart Center, Munich, Germany.,Department of Cardiology, University Hospital Bonn, Germany
| | - Arne Pfeufer
- Institute of Bioinformatics and Systems Biology, Helmholtz Zentrum Munich, Germany
| | | | | | | | | | - Thorsten Lewalter
- Isar Heart Center, Munich, Germany.,Peter Osypka Heart Center, Munich, Germany.,Department of Cardiology, University Hospital Bonn, Germany
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24
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Grimaldi M, Swarup V, DeVille B, Sussman J, Jaïs P, Gaita F, Duytschaever M, Ng GA, Daoud E, Lakkireddy DDJ, Horton R, Wickliffe A, Ellis C, Geller L. Importance of anticoagulation and postablation silent cerebral lesions: Subanalyses of REVOLUTION and reMARQable studies. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1432-1439. [DOI: 10.1111/pace.13205] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 09/05/2017] [Accepted: 09/22/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Massimo Grimaldi
- Ospedale Generale “F. Miulli,” Acquaviva delle Fonti (Ba); Italy
| | | | | | | | - Pierre Jaïs
- CHU Bordeaux; University of Bordeaux; IHU LIRYC ANR-10-IAHU-04 France
| | - Fiorenzo Gaita
- Città della Salute e della Scienza di Torino, Medical Sciences Department; University of Turin; Italy
| | | | - G. Andre Ng
- University of Leicester, NIHR Biomedical Research Centre; Glenfield Hospital; Leicester UK
| | - Emile Daoud
- Ohio State University Davis Heart and Lung Research Institute; Columbus OH USA
| | | | - Rodney Horton
- Texas Cardiac Arrhythmia Research Foundation; TX USA
| | | | | | - Laszlo Geller
- Semmelweis University Heart Center; Budapest Hungary
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25
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Aagaard P, Briceno D, Csanadi Z, Mohanty S, Gianni C, Trivedi C, Nagy-Baló E, Danik S, Barrett C, Santoro F, Burkhardt JD, Sanchez J, Natale A, Di Biase L. Atrial Fibrillation Ablation and Stroke. Cardiol Clin 2017; 34:307-16. [PMID: 27150179 DOI: 10.1016/j.ccl.2015.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Catheter ablation has become a widely available and accepted treatment to restore sinus rhythm in atrial fibrillation patients who fail antiarrhythmic drug therapy. Although generally safe, the procedure carries a non-negligible risk of complications, including periprocedural cerebral insults. Uninterrupted anticoagulation, maintenance of an adequate ACT during the procedure, and measures to avoid and detect thrombus build-up on sheaths and atheters during the procedure, appears useful to reduce the risk of embolic events. This is a review of the incidence, mechanisms, impact, and methods to reduce catheter ablation related cerebral insults.
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Affiliation(s)
- Philip Aagaard
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Hospital, Bronx, NY, USA
| | - David Briceno
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Hospital, Bronx, NY, USA
| | - Zoltan Csanadi
- Department of Cardiology, University of Debrecen, 22 Móricz Zs, Debrecen H4032, Hungary
| | - Sanghamitra Mohanty
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Carola Gianni
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Chintan Trivedi
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Edina Nagy-Baló
- Department of Cardiology, University of Debrecen, 22 Móricz Zs, Debrecen H4032, Hungary
| | - Stephan Danik
- The Al-Sabah Arrhythmia Institute at Mount Sinai St. Luke, New York, NY, USA
| | - Conor Barrett
- The Al-Sabah Arrhythmia Institute at Mount Sinai St. Luke, New York, NY, USA
| | | | - J David Burkhardt
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Javier Sanchez
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Andrea Natale
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA; Division of Cardiology, Stanford University, Stanford, CA, USA; CaseWestern Reserve University, Cleveland, OH, USA; EP Services, California Pacific Medical Center, San Francisco, CA, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Dell Medical School, University of Texas, Austin, TX, USA.
| | - Luigi Di Biase
- Department of Cardiology, Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA; Department of Cardiology, University of Foggia, Foggia, Italy; Department of Biomedical Engineering, University of Texas, Austin, TX, USA.
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26
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Barnett AS, Bahnson TD, Piccini JP. Recent Advances in Lesion Formation for Catheter Ablation of Atrial Fibrillation. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.115.003299. [PMID: 27103088 DOI: 10.1161/circep.115.003299] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 02/12/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Adam S Barnett
- From the Duke Center for Atrial Fibrillation, Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC
| | - Tristram D Bahnson
- From the Duke Center for Atrial Fibrillation, Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC
| | - Jonathan P Piccini
- From the Duke Center for Atrial Fibrillation, Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC.
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27
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LIU XIAOHUA, CHEN CHAOFENG, GAO XIAOFEI, XU YIZHOU. Safety and Efficacy of Different Catheter Ablations for Atrial Fibrillation: A Systematic Review and Meta-Analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:883-99. [PMID: 27197002 DOI: 10.1111/pace.12889] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 04/25/2016] [Accepted: 04/30/2016] [Indexed: 12/30/2022]
Affiliation(s)
- XIAO-HUA LIU
- Hangzhou Hospital of Zhejiang Chinese Medical University; Shangcheng District Hangzhou City Zhejiang Province China
| | - CHAO-FENG CHEN
- Department of Cardiology; Hangzhou Hospital of Nanjing Medical University; Shangcheng District Hangzhou City Zhejiang Province China
| | - XIAO-FEI GAO
- Hangzhou Hospital of Zhejiang Chinese Medical University; Shangcheng District Hangzhou City Zhejiang Province China
| | - YI-ZHOU XU
- Department of Cardiology; Hangzhou Hospital of Nanjing Medical University; Shangcheng District Hangzhou City Zhejiang Province China
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28
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Hahne K, Mönnig G, Samol A. Atrial fibrillation and silent stroke: links, risks, and challenges. Vasc Health Risk Manag 2016; 12:65-74. [PMID: 27022272 PMCID: PMC4788372 DOI: 10.2147/vhrm.s81807] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia, with a projected number of 1 million affected subjects in Germany. Changes in age structure of the Western population allow for the assumption that the number of concerned people is going to be doubled, maybe tripled, by the year 2050. Large epidemiological investigations showed that AF leads to a significant increase in mortality and morbidity. Approximately one-third of all strokes are caused by AF and, due to thromboembolic cause, these strokes are often more severe than those caused by other etiologies. Silent brain infarction is defined as the presence of cerebral infarction in the absence of corresponding clinical symptomatology. Progress in imaging technology simplifies diagnostic procedures of these lesions and leads to a large amount of diagnosed lesions, but there is still no final conclusion about frequency, risk factors, and clinical relevance of these infarctions. The prevalence of silent strokes in patients with AF is higher compared to patients without AF, and several studies reported high incidence rates of silent strokes after AF ablation procedures. While treatment strategies to prevent clinically apparent strokes in patients with AF are well investigated, the role of anticoagulatory treatment for prevention of silent infarctions is unclear. This paper summarizes developments in diagnosis of silent brain infarction and its context to AF.
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Affiliation(s)
- Kathrin Hahne
- Division of Cardiology, University Hospital Münster, Münster, Germany
| | - Gerold Mönnig
- Division of Electrophysiology, Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | - Alexander Samol
- Division of Cardiology, University Hospital Münster, Münster, Germany
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29
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Forleo GB, Della Rocca DG, Lavalle C, Mantica M, Papavasileiou LP, Ribatti V, Panattoni G, Santini L, Natale A, Biase LD. A Patient With Asymptomatic Cerebral Lesions During AF Ablation: How Much Should We Worry? J Atr Fibrillation 2016; 8:1323. [PMID: 27909472 PMCID: PMC5089485 DOI: 10.4022/jafib.1323] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 01/09/2023]
Abstract
Silent brain lesions due to thrombogenicity of the procedure represent recognized side effects of atrial fibrillation (AF) catheter ablation. Embolic risk is higher if anticoagulation is inadequate and recent studies suggest that uninterrupted anticoagulation, ACT levels above 300 seconds and administration of a pre-transeptal bolus of heparin might significantly reduce the incidence of silent cerebral ischemia (SCI) to 2%. Asymptomatic new lesions during AF ablation should suggest worse neuropsychological outcome as a result of the association between silent cerebral infarcts and increased long-term risk of dementia in non-ablated AF patients. However, the available data are discordant. To date, no study has definitely linked post-operative asymptomatic cerebral events to a decline in neuropsychological performance. Larger volumes of cerebral lesions have been associated with cognitive decline but are uncommon findings acutely in post-ablation AF patients. Of note, the majority of acute lesions have a small or medium size and often regress at a medium-term follow-up. Successful AF ablation has the potential to reduce the risk of larger SCI that may be considered as part of the natural course of AF. Although the long-term implications of SCI remain unclear, it is conceivable that strategies to reduce the risk of SCI may be beneficial.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Andrea Natale
- Policlinico Tor Vergata, Rome, Italy; Policlinico Tor Vergata, Rome, Italy
| | - Luigi Di Biase
- Policlinico Tor Vergata, Rome, Italy; Policlinico Tor Vergata, Rome, Italy
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30
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Nakamura K, Naito S, Sasaki T, Minami K, Take Y, Goto E, Shimizu S, Yamaguchi Y, Suzuki N, Yano T, Senga M, Kumagai K, Kaseno K, Funabashi N, Oshima S. Silent Cerebral Ischemic Lesions After Catheter Ablation of Atrial Fibrillation in Patients on 5 Types of Periprocedural Oral Anticoagulation – Predictors of Diffusion-Weighted Imaging-Positive Lesions and Follow-up Magnetic Resonance Imaging –. Circ J 2016; 80:870-7. [DOI: 10.1253/circj.cj-15-1368] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Eri Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Satoru Shimizu
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | | | - Naoko Suzuki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Toshiaki Yano
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Michiharu Senga
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Koji Kumagai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kenichi Kaseno
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine
| | - Shigeru Oshima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
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31
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Wissner E, Deiss S, Kuck KH. Balloon-based pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation (cryoballoon and laserballoon). Future Cardiol 2015; 11:663-71. [PMID: 26610028 DOI: 10.2217/fca.15.68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Electrical isolation of the pulmonary veins still remains one of the major objectives during catheter ablation of atrial fibrillation. In patients with paroxysmal atrial fibrillation, balloon-based technologies hold great promise to simplify the approach to successful pulmonary vein isolation. While the cryoballoon represents the only true 'single-shot' technology, the laserballoon allows real-time endoscopic visualization of the pulmonary vein antrum during energy delivery. Either technology aims at complete electrical isolation, requiring continuous transmural lesion sets encircling the pulmonary veins. Strategies to confirm and to improve upon the efficacy of pulmonary vein isolation are the key to acute and long-term clinical success and will be reviewed in this article.
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Affiliation(s)
- Erik Wissner
- Department of Cardiology, Asklepios Klinik St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
| | - Sebastian Deiss
- Department of Cardiology, Asklepios Klinik St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
| | - Karl-Heinz Kuck
- Department of Cardiology, Asklepios Klinik St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
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32
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Metzner A, Wissner E, Lin T, Ouyang F, Kuck KH. Balloon Devices for Atrial Fibrillation Therapy. Arrhythm Electrophysiol Rev 2015; 4:58-61. [PMID: 26835102 DOI: 10.15420/aer.2015.4.1.58] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 02/25/2015] [Indexed: 11/04/2022] Open
Abstract
Ablation of atrial fibrillation (AF) is an established treatment option for symptomatic patients refractory to antiarrhythmic medication. In patients with paroxysmal AF, ablation can be offered as first-line therapy when performed in an experienced centre. The accepted cornerstone for all ablation strategies is isolation of the pulmonary veins. However, it is still challenging to achieve contiguous, transmural, permanent lesions using radio-frequency current (RFC) based catheters in conjunction with a three-dimensional mapping system and the learning curve remains long. These limitations have kindled interest in developing and evaluating novel catheter designs that incorporate alternative energy sources. Novel catheters include balloon-based ablation systems, incorporating different energy modalities such as laser (Heartlight(™), CardioFocus, Marlborough, MA, US), RFC (Hot Balloon Catheter, Hayama Arrhythmia Institute, Kanagawa, Japan) and cryo-energy (ArcticFront, Medtronic, Inc., Minneapolis, MN, US). While the cryoballoon (CB) and the radiofrequency hot balloon (RHB) are single-shot devices, the endoscopic ablation system (EAS) allows for point-by-point ablation. The CB and EAS are well established as safe, time-efficient and effective ablation tools. Initial studies using the RHB could also demonstrate promising results. However, more data are required.
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33
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DENEKE THOMAS, JAIS PIERRE, SCAGLIONE MARCO, SCHMITT RAINER, DI BIASE LUIGI, CHRISTOPOULOS GEORGIOS, SCHADE ANJA, MÜGGE ANDREAS, BANSMANN MARTIN, NENTWICH KARIN, MÜLLER PATRICK, KRUG JOACHIM, ROOS MARKUS, HALBFASS PHILLIP, NATALE ANDREA, GAITA FIORENZO, HAINES DAVID. Silent Cerebral Events/Lesions Related to Atrial Fibrillation Ablation: A Clinical Review. J Cardiovasc Electrophysiol 2015; 26:455-463. [DOI: 10.1111/jce.12608] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 12/11/2014] [Indexed: 11/30/2022]
Affiliation(s)
- THOMAS DENEKE
- Heart Center Bad Neustadt; Bad Neustadt Germany
- Ruhr-University Bochum; Bochum Germany
| | | | - MARCO SCAGLIONE
- Cardiology Division; Cardinal Guglielmo Massaia Hospital; Asti Italy
| | - RAINER SCHMITT
- Department of Radiology; Heart Center Bad Neustadt; Bad Neustadt Germany
| | - LUIGI DI BIASE
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
- Department of Biomedical Engineering; University of Texas; Austin Texas USA
- Department of Cardiology; University of Foggia; Foggia Italy
- Albert Einstein College of Medicine at Montefiore Hospital New York; New York USA
| | | | - ANJA SCHADE
- Heart Center Bad Neustadt; Bad Neustadt Germany
| | | | - MARTIN BANSMANN
- Institute for Diagnostic and Interventional Radiology; Hospital Cologne-Porz; Germany
| | | | - PATRICK MÜLLER
- Heart Center Bad Neustadt; Bad Neustadt Germany
- Ruhr-University Bochum; Bochum Germany
| | | | - MARKUS ROOS
- Heart Center Bad Neustadt; Bad Neustadt Germany
| | | | - ANDREA NATALE
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
- Ruhr-University Bochum; Bochum Germany
| | - FIORENZO GAITA
- Division of Cardiology; Department of Medical Sciences; University of Turin; Italy
| | - DAVID HAINES
- Department of Cardiovascular Medicine; Oakland University William Beaumont School of Medicine; Royal Oak Michigan USA
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Lin T, Wissner E, Tilz R, Rillig A, Mathew S, Rausch P, Rausch P, Lemes C, Deiss S, Kamioka M, Bucur T, Ouyang F, Kuck KH, Metzner A. Preserving Cognitive Function in Patients with Atrial Fibrillation. J Atr Fibrillation 2014; 7:980. [PMID: 27957071 DOI: 10.4022/jafib.980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 05/22/2014] [Accepted: 05/23/2014] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and is associated with significant morbidity and mortality. Its prevalence increases with increasing age, and is one of the leading causes of thromboembolism, including ischemic stroke. The prevalence of cognitive dysfunction also increases with increasing age. Although several studies have shown a strong correlation between AF and cognitive dysfunction in patients with and without overt stroke, a direct causative link has yet to be established. Rhythm vs rate control and anticoagulation regimens have been extensively investigated, particularly with the introduction of the novel anticoagulants. With catheter ablation becoming more prevalent for the management of AF and the ongoing development of various new energy sources and catheters, an additional thromboembolism risk is introduced. As cognitive dysfunction decreases the patient's ability to self-care and manage a complex disease such as AF, this increases the burden to our healthcare system. Therefore as the prevalence of AF increases in the general population, it becomes more imperative that we strive to optimize our methods to preserve cognitive function. This review gives an overview of the current evidence behind the association of AF with cognitive dysfunction, and discusses the most up-to-date medical and procedural treatment strategies available for decreasing thromboembolism associated with AF and its treatment, which may lead to preserving cognitive function.
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Affiliation(s)
- Tina Lin
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Erik Wissner
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Roland Tilz
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Andreas Rillig
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Shibu Mathew
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Peter Rausch
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Peter Rausch
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Christine Lemes
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Sebastian Deiss
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Masashi Kamioka
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Tudor Bucur
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Feifan Ouyang
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Karl-Heinz Kuck
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
| | - Andreas Metzner
- Asklepios-Klinik St. Georg, Dept. Of Cardiology, Lohmühlenstr. 5, 20099 Hamburg/Germany
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35
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Influence of cardioversion on asymptomatic cerebral lesions following atrial fibrillation ablation. J Interv Card Electrophysiol 2014; 40:129-36. [PMID: 24928483 DOI: 10.1007/s10840-014-9904-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 04/11/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Asymptomatic cerebral lesions detected by diffusion-weighted magnetic resonance imaging (MRI) following atrial fibrillation (AF) ablation were reported in recent years. It was reported that cardioversion during the procedure of AF ablation was one independent risk factor of asymptomatic cerebral lesions. However, in some studies, the similar association between asymptomatic cerebral lesions and intraprocedural cardioversion was not observed. Given the inconsistent results, we did a meta-analysis to explore the influence of intraprocedural cardioversion on the asymptomatic cerebral lesions detected by MRI following AF ablation. METHODS Studies exploring the association between cardioversion during AF ablation and asymptomatic cerebral lesions following AF ablation were systematically searched in PubMed, Web of Science and the Cochrane Library Databases. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled. Subgroup and sensitivity analyses were performed to explore the source of heterogeneity. RESULTS Nine studies involving 813 participants were included in the present meta-analysis. When we pooled data from nine studies using fixed-effects model, we found cardioversion during the procedure significantly increased the risk of asymptomatic cerebral lesions detected by MRI following AF ablation (pooled OR = 1.793, 95% CI 1.201-2.678, I (2) = 38.8%, P heterogeneity = 0.109). CONCLUSIONS Cardioversion during AF ablation significantly increased the risk of asymptomatic cerebral lesions on MRI following the procedure. Additional studies are required to further verify the association.
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36
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Guijian L, Wenqing Z, Xinggang W, Ying Y, Minghui L, Yeqing X, Ruizhen C, Junbo G. Association between ablation technology and asymptomatic cerebral injury following atrial fibrillation ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:1378-91. [PMID: 24888771 DOI: 10.1111/pace.12432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/23/2014] [Accepted: 04/27/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Asymptomatic cerebral injury (ACI) detected by diffusion-weighted magnetic resonance imaging (MRI) following atrial fibrillation (AF) ablation has been reported recently. The purpose of this study was to provide an overview of the incidence of ACI detected by MRI following AF ablation and to explore the association between ablation technology and ACI by systematically reviewing published trials. METHODS AND RESULTS PubMed, Web of Science, and the Cochrane Library Databases were systematically searched for studies exploring ACI detected by MRI following AF ablation. Incidence of ACI, odds ratios, and 95% confidence intervals (CIs) were pooled. We identified 21 eligible studies. The combined ACI incidence across all studies was 15.9% (95% CI: 0.124-0.202). We also did a subgroup analysis stratified by different technologies. The incidence of ACI stratified by ablation technology was 13.0%, 27.6%, 12.5%, 17.3%, and 32.6% of the irrigated radiofrequency (RF), multielectrode-phased RF pulmonary vein ablation catheter (PVAC), cryoballoon, laser balloon, and nMARQTM groups, respectively. CONCLUSIONS The incidence of ACI following AF ablation with PVAC was higher than with other technologies. Uninterrupted oral anticoagulant (OAC) during the procedure could lower the incidence of ACI. It seems prudent not to interrupt OACs during the procedure. In addition, intraprocedural activated clotting time was associated with ACI. Different MRI diagnostic criteria for ACI also influenced the results. To facilitate the future research, a generally accepted definition for silent cerebrovascular ischemia suitable to different kinds of MRI is needed.
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Affiliation(s)
- Liu Guijian
- Key Laboratory of Viral Heart Diseases, Ministry of Public Health, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
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