Long-Term Stroke Risk in Patients Undergoing Left Atrial Appendage Ablation With and Without Complete Isolation

Abstract

Background: Catheter ablation (CA) for atrial fibrillation (AF), may require ablation beyond the pulmonary veins. Prior data suggest that additional LA ablation, particularly left atrial appendage (LAA) ablation, may alter atrial function leading to increased risk of ischemic stroke or transient ischemic attack (IS/TIA). We sought to study the long-term risk of IS/TIA in patients receiving ablation at the LAA compared to those receiving PVI alone and those receiving PVI with additional non-LAA locations.Methods: 350 patients who underwent CA for AF from 2008 to 2018 were included in the study. Locations of ablation in LA evaluated were the posterior wall, anterior wall, inferior wall, inter-atrial septum, lateral wall and the left atrial appendage (LAA). Patients undergoing LAA ablation were further divided as complete isolation (LAAi) and without complete isolation (LAAa).Results: Mean follow up of 4.8 years. In entire cohort, risk of IS/TIA was 1.62/100 patient-years (pys). The risk was highest in patients with LAAi (3.81/100 pys), followed by ablation LAAa (3.74/100 pys). Amongst all LA locations, only LAAi (HR 3.32, p = 0.03) and LAAa (HR 3.18, p = 0.02) were statistically significant predictors of IS/TIA after adjusting for OAC (Oral anticoagulant) use and baseline CHA2DS2VASc score.Conclusions: During long term follow-up, only ablation at the left atrial appendage with and without complete isolation was independently associated with an increased risk of IS/TIA in patients undergoing CA for AF. Potential strategies to reduce stroke risk, such as LAA closure, should be considered in these patients.

Differences in postablation cardiac MRI scar between radiofrequency and cryoballoon ablation: A DECAAF II subanalysis

“…While this observation requires further investigation to prove causality it may help explain why the DECAAF II trial was negative because targeting LA fibrosis far from the PV antra did not improve freedom from AAR 7 . Scar formation is not without risk however, and clinicians must balance the benefits of ablation with the risk of a stiff left atrial syndrome, esophageal injury, and stroke 34–36 . Overall, the percentage and location of postablation LA scar may help clinicians predict which patients recur after PVI and consider additional strategies for rhythm control.…”

“…7 Scar formation is not without risk however, and clinicians must balance the benefits of ablation with the risk of a stiff left atrial syndrome, esophageal injury, and stroke. [34][35][36] Overall, the percentage and location of postablation LA scar may help clinicians predict which patients recur after PVI and consider additional strategies for rhythm control. The ability of postablation LA scar percentage and regionality to predict AAR highlights the importance of obtaining postablation CMR.…”