Incidence of Asymptomatic Intracranial Embolic Events After Pulmonary Vein Isolation

Abstract

The PVAC is associated with a significantly higher incidence of subclinical intracranial embolic events. Further study of the causes and significance of these emboli is required to determine the safety of the PVAC.

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…Following initial, mostly single-center, experiences that demonstrated excellent clinical efficacy, several studies reported a high incidence of asymptomatic cerebral emboli (ACE) lesions after PVI with the PVAC compared with irrigated focal RF and CBA. 650,723,724,725,726,727 These reports triggered an evaluation of the underlying mechanisms; the Endovascular Revascularization and Supervised Exercise Therapy in Patients with Peripheral Artery Disease and Intermittent Claudication trial subsequently demonstrated that through modifications in the catheter design, including the elimination of overlying pole 1 and 10 ablation, and protocol for use, it was possible to reduce the incidence of ACE lesions to 1.7%. 722,727,728,729,730 These findings were confirmed in the PRECISION GOLD trial.…”

“…Subsequent to this report, multiple studies have reported that DW-MRI can detect new acute lesions created by emboli, following up to 50% of AF ablation procedures. 723,724,800,1205,1207,1208,1209 …”

“…724,728,1207 The clinical significance of such ACE lesions is not known, and many will resolve to the point of being undetectable after weeks or months. The impact on cognitive function, if any, is not clear.…”

Multielectrode Pulmonary Vein Isolation Versus Single Tip Wide Area Catheter Ablation for Paroxysmal Atrial Fibrillation

“…In 2010, Gaita et al 19 showed that asymptomatic cerebral embolism (ACE) in 11% of patients accompanied AF ablation. Subsequent registries 20,21 showed that the ACE rate seemed to be higher for PVAC than for focal irrigated radiofrequency and cryoballoon ablation. Further investigation by Haines et al 22 demonstrated that the root cause for embolism was electrode overheating, which was predominantly found when electrodes 1 and 10 were in close proximity during ablation.…”

Cryoballoon Ablation for Atrial Fibrillation

“…Similarly, two recent studies comprising a total of 182 patients compared the incidence of silent cerebral ischemic lesions after PV isolation with duty-cycled multi-electrode ablation, conventional irrigated-tip RF ablation, and CBA. In both studies the incidence of new silent cerebral ischemic lesions, which have been associated with neurocognitive decline, was found to be significantly higher with multi-electrode ablation (37.5-38.9%) when compared to irrigated RF (7.4-8.3%) or CBA (4.3-5.6; overall P=0.008 for Siklody et al, and overall P=0.002 for Gaita et al) [34,35]. …”