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; CHA₂DS₂-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.

Supporting Information

REFERENCES

1Calkins H, Kuck KH, Cappato R, et al. 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: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm. 2012; 9: 632–696.e621.
10.1016/j.hrthm.2011.12.016
PubMed Web of Science® Google Scholar
2Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. 2010; 3: 32–38.
10.1161/CIRCEP.109.859116
PubMed Web of Science® Google Scholar
3Arbelo E, Brugada J, Hindricks G, et al. Atrial Fibrillation Ablation Pilot Study I. The atrial fibrillation ablation pilot study: A European Survey on Methodology and results of catheter ablation for atrial fibrillation conducted by the European Heart Rhythm Association. Eur Heart J. 2014; 35: 1466–1478.
10.1093/eurheartj/ehu001
PubMed Web of Science® Google Scholar
4Lickfett L, Hackenbroch M, Lewalter T, et al. Cerebral diffusion-weighted magnetic resonance imaging: A tool to monitor the thrombogenicity of left atrial catheter ablation. J Cardiovasc Electrophysiol. 2006; 17: 1–7.
10.1111/j.1540-8167.2005.00279.x
CAS PubMed Web of Science® Google Scholar
5Sediva L, Petru J, Skoda J, et al. Visually guided laser ablation: A single-centre long-term experience. Europace. 2014; 16: 1746–1751.
10.1093/europace/euu168
PubMed Web of Science® Google Scholar
6Wissner E, Metzner A, Neuzil P, et al. Asymptomatic brain lesions following laserballoon-based pulmonary vein isolation. Europace. 2014; 16: 214–219.
10.1093/europace/eut250
PubMed Web of Science® Google Scholar
7Schmidt B, Gunawardene M, Krieg D, et al. A prospective randomized single-center study on the risk of asymptomatic cerebral lesions comparing irrigated radiofrequency current ablation with the cryoballoon and the laser balloon. J Cardiovasc Electrophysiol. 2013; 24: 869–874.
10.1111/jce.12151
CAS PubMed Web of Science® Google Scholar
8Deneke T, Nentwich K, Schmitt R, et al. Exchanging catheters over a single transseptal sheath during left atrial ablation is associated with a higher risk for silent cerebral events. Indian Pacing Electrophysiol J. 2014; 14: 240–249.
10.1016/S0972-6292(16)30795-1
PubMed Google Scholar
9Dukkipati SR, Neuzil P, Skoda J, et al. Visual balloon-guided point-by-point ablation: Reliable, reproducible, and persistent pulmonary vein isolation. Circ Arrhythm Electrophysiol. 2010; 3: 266–273.
10.1161/CIRCEP.109.933283
PubMed Web of Science® Google Scholar
10Metzner A, Wissner E, Schmidt B, et al. Acute and long-term clinical outcome after endoscopic pulmonary vein isolation: Results from the first prospective, multicenter study. J Cardiovasc Electrophysiol. 2013; 24: 7–13.
10.1111/j.1540-8167.2012.02427.x
PubMed Web of Science® Google Scholar
11Schmidt B, Gunawardene M, Urban V, et al. Visually guided sequential pulmonary vein isolation: Insights into techniques and predictors of acute success. J Cardiovasc Electrophysiol. 2012; 23: 576–582.
10.1111/j.1540-8167.2011.02247.x
CAS PubMed Web of Science® Google Scholar
12Toth O, Calatzis A, Penz S, Losonczy H, Siess W. Multiple electrode aggregometry: A new device to measure platelet aggregation in whole blood. Thromb Haemost. 2006; 96: 781–788.
10.1160/TH06-05-0242
CAS PubMed Web of Science® Google Scholar
13von Pape KW, Dzijan-Horn M, Bohner J, Spannagl M, Weisser H, Calatzis A. [Control of aspirin effect in chronic cardiovascular patients using two whole blood platelet function assays. PFA-100 and Multiplate]. Hamostaseologie. 2007; 27: 155–160;quiz 161–152.
PubMed Google Scholar
14Jambor C, Weber CF, Gerhardt K, et al. Whole blood multiple electrode aggregometry is a reliable point-of-care test of aspirin-induced platelet dysfunction. Anesth Analg. 2009; 109: 25–31.
10.1213/ane.0b013e3181a27d10
CAS PubMed Web of Science® Google Scholar
15von Bary C, DenekeT, Arentz T, et al. Silent cerebral events as a result of left atrial catheter ablation do not cause neuropsychological sequelae–a MRI-controlled multicenter study. J Interv Card Electrophysiol. 2015; 43: 217–226.
10.1007/s10840-015-0004-6
PubMed Web of Science® Google Scholar
16Sramko M, Peichl P, Wichterle D, et al. A novel biomarker-based approach for the detection of asymptomatic brain injury during catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2014; 25: 349–354.
10.1111/jce.12325
CAS PubMed Web of Science® Google Scholar
17Wieczorek M, Hoeltgen R, Brueck M. Does the number of simultaneously activated electrodes during phased RF multielectrode ablation of atrial fibrillation influence the incidence of silent cerebral microembolism. Heart Rhythm. 2013; 10: 953–959.
10.1016/j.hrthm.2013.04.005
PubMed Web of Science® Google Scholar
18Haeusler KG, Koch L, Herm J, et al. 3 Tesla MRI-detected brain lesions after pulmonary vein isolation for atrial fibrillation: Results of the MACPAF study. J Cardiovasc Electrophysiol. 2013; 24: 14–21.
10.1111/j.1540-8167.2012.02420.x
PubMed Web of Science® Google Scholar
19Deneke T, Jais P, Scaglione M, et al. Silent cerebral events/lesions related to atrial fibrillation ablation: A clinical review. J Cardiovasc Electrophysiol. 2015; 26: 455–463.
10.1111/jce.12608
PubMed Web of Science® Google Scholar
20Kuhl CK, Textor J, Gieseke J, et al. Acute and subacute ischemic stroke at high-field-strength (3.0-T) diffusion-weighted MR imaging: Intraindividual comparative study. Radiology. 2005; 234: 509–516.
10.1148/radiol.2342031323
PubMed Web of Science® Google Scholar
21Deneke T, Shin DI, Balta O, et al. Postablation asymptomatic cerebral lesions: Long-term follow-up using magnetic resonance imaging. Heart Rhythm. 2011; 8: 1705–1711.
10.1016/j.hrthm.2011.06.030
PubMed Web of Science® Google Scholar
22Rillig A, Meyerfeldt U, Tilz RR, et al. Incidence and long-term follow-up of silent cerebral lesions after pulmonary vein isolation using a remote robotic navigation system as compared with manual ablation. Circ Arrhythm Electrophysiol. 2012; 5: 15–21.
10.1161/CIRCEP.111.967497
PubMed Web of Science® Google Scholar
23Martinek M, Sigmund E, Lemes C, et al. Asymptomatic cerebral lesions during pulmonary vein isolation under uninterrupted oral anticoagulation. Europace. 2013; 15: 325–331.
10.1093/europace/eus329
PubMed Web of Science® Google Scholar
24Wieczorek M, Lukat M, Hoeltgen R, et al. Investigation into causes of abnormal cerebral MRI findings following PVAC duty-cycled, phased RF ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2013; 24: 121–128.
10.1111/jce.12006
PubMed Web of Science® Google Scholar
25Kuwahara T, Abe M, Yamaki M, et al. Apixaban versus warfarin for the prevention of periprocedural cerebral thromboembolism in atrial fibrillation ablation: Multicenter prospective randomized study. J Cardiovasc Electrophysiol. 2016; 27: 549–554.
10.1111/jce.12928
PubMed Web of Science® Google Scholar
26Anfinsen OG, Gjesdal K, Brosstad F, et al. The activation of platelet function, coagulation, and fibrinolysis during radiofrequency catheter ablation in heparinized patients. J Cardiovasc Electrophysiol. 1999; 10: 503–512.
10.1111/j.1540-8167.1999.tb00706.x
CAS PubMed Web of Science® Google Scholar
27Lee DS, Dorian P, Downar E, Burns M, et al. Thrombogenicity of radiofrequency ablation procedures: What factors influence thrombin generation. Europace. 2001; 3: 195–200.
10.1053/eupc.2001.0167
CAS PubMed Web of Science® Google Scholar
28Di Biase L, Gaita F, Toso E, et al. Does periprocedural anticoagulation management of atrial fibrillation affect the prevalence of silent thromboembolic lesion detected by diffusion cerebral magnetic resonance imaging in patients undergoing radiofrequency atrial fibrillation ablation with open irrigated catheters? Results from a prospective multicenter study. Heart Rhythm. 2014; 11: 791–798.
10.1016/j.hrthm.2014.03.003
PubMed Web of Science® Google Scholar
29Zeymer U, Hohlfeld T, Vom Dahl J, et al. Prospective, randomised trial of the time dependent antiplatelet effects of 500 mg and 250 mg acetylsalicylic acid i. v. and 300 mg p. o. in ACS (ACUTE). Thromb Haemost. 2017; 117: 625–635.
10.1160/TH16-08-0650
PubMed Web of Science® Google Scholar
30Loew D, Belz GG. Acetylsalicylic acid (ASA) - how much, how often, and when? A clinical-pharmacological perspective. Int J Clin Pharmacol Ther. 2016; 54: 634–639.
10.5414/CP202539
CAS PubMed Web of Science® Google Scholar
31Gaita F, Caponi D, Pianelli M, et al. Radiofrequency catheter ablation of atrial fibrillation: A cause of silent thromboembolism? Magnetic resonance imaging assessment of cerebral thromboembolism in patients undergoing ablation of atrial fibrillation. Circulation. 2010; 122: 1667–1673.
10.1161/CIRCULATIONAHA.110.937953
PubMed Web of Science® Google Scholar
32Scaglione M, Blandino A, Raimondo C, et al. Impact of ablation catheter irrigation design on silent cerebral embolism after radiofrequency catheter ablation of atrial fibrillation: Results from a pilot study. J Cardiovasc Electrophysiol. 2012; 23: 801–805.
10.1111/j.1540-8167.2012.02298.x
CAS PubMed Web of Science® Google Scholar
33Ichiki H, Oketani N, Ishida S, et al. Incidence of asymptomatic cerebral microthromboembolism after atrial fibrillation ablation guided by complex fractionated atrial electrogram. J Cardiovasc Electrophysiol. 2012; 23: 567–573.
10.1111/j.1540-8167.2011.02259.x
CAS PubMed Web of Science® Google Scholar

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Volume29, Issue3

March 2018

Pages 365-374

REduction of THRomboembolic EVents during Ablation using the laserballoon: The RETHREVA registry

Abstract

Introduction

Methods and results

Conclusion

Supporting Information

REFERENCES

Citing Literature

References

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REduction of THRomboembolic EVents during Ablation using the laserballoon: The RETHREVA registry

Abstract

Introduction

Methods and results

Conclusion

Supporting Information

REFERENCES

Citing Literature

References

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