Asymptomatic cerebral embolism Thromboembolism 4 (0.4%) after AF - - PowerPoint PPT Presentation

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Asymptomatic cerebral embolism Thromboembolism 4 (0.4%) after AF - - PowerPoint PPT Presentation

May 03, 2023 182 likes •298 views

Complications of AF Ablation in a High-Volume Center in 1,000 Procedures: Still Cause for Concern? Dagres JCE 2009 Death (procedural/late) 0/2 (0/0.2%) Atrio-esophageal fistula 2 (0.2%) Asymptomatic cerebral embolism Thromboembolism 4

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SLIDE 1

1

Asymptomatic cerebral embolism after AF ablation

Jonathan Kalman Royal Melbourne Hospital No Disclosures

Complications of AF Ablation in a High-Volume Center in 1,000 Procedures: Still Cause for Concern?

Death (procedural/late) 0/2 (0/0.2%) Atrio-esophageal fistula 2 (0.2%) Thromboembolism 4 (0.4%) Stroke 3 (0.3%) TIA 1 (0.1%) Tamponade 13 (1.3%) Severe PV stenosis 1 (0.1%) Endocarditis 2 (0.2%) Retroperit hematoma 1 (0.1%) Aspiration Pneumonia 2 (0.2%) Femoral Cxs 12 (1.2%) TOTAL 39 (3.9%)

Dagres JCE 2009

Peri-procedural stroke/TIA risk in AF ablation: registries & cohort studies

Stroke / TIA n F/up (days) ACT (secs) Hussein, HR 2009

0.1% 3052 1 350-450, INR≥1.8

Di Biase Circ 2010

0.6% 6454 2 ≥350; INR≥2

Patel JCE 2010

0.85% 3060 2 250-450

Spragg JCE 2008

1.09% 641 1 300-400

Bertaglia HR 2007

0.5% 1011 1-2 300-400

Scherr JCE 2009

1.39% 721 6 300-400

Dagres JCE 2009

0.4% 1000 8 300

Cappato CAE 2010

0.94% 20,825

  • 200-350

Incidence & predictors of periprocedural CVA in AF ablation pts

Scherr et al, J Cardiovasc Electrophys 2009

10 CVA’s / 721 pts (1.4%)

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SLIDE 2

2 Potential mechanisms underlying thromboembolism in AF ablation procedures

  • AF reversion: atrial “stunning”
  • Multiple intra-LA catheters/sheaths
  • Char formation
  • Endothelial disruption
  • Activation of coagulation factors

Atrial “stunning” immediately post RF flutter reversion Chronic Atrial Flutter Sinus Rhythm

LA LASEC LV LV

0 cm/s 40 cm/s

Sparks, Kalman JACC 1999

LA Thrombus During AF RFA: ICE Imaging

Ren et al, JACC 2004

  • ACT >250
  • LA thrombus in 24/232 pts (10.3%).
  • Thrombi 12.9 X 2.2 mm (width)
  • Attached to sheath or mapping catheter.
  • Thrombi (27 of 30, 90%) aspirated into sheath
  • No clinical embolic events.
  • SEC, best predictor on multivariate analysis

Increased anticoagulation intensity reduces thrombus risk during AF ablation

ACT 250-300 ACT >300 p All pts (n=511) 11.2% 2.8% <0.05 Pts with SEC (n=179) 44.9% 4.6% <0.0001

Ren et al, J Cardiovasc electrophysiol 2005

Incidence of ICE detected mobile thrombus

(on sheath/catheter after T/septal)

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SLIDE 3

3 Phased-Array ICE monitoring during PVI in pts with AF: Reduction of embolic events

Marrouche et al. Circulation 2003: 107: 2710 Dense Microbubbles Imminent impedance rise → RF turned off Scattered Microbubble Early Tissue Overheating → Power reduced by 5 watts

Type 1 bubbles Type 2 bubbles

Phased-Array ICE monitoring during PVI in pts with AF: Impact on outcome & complications

Marrouche et al. Circulation 2003: 107: 2710

2012 HRS/EHRA/ECAS Expert Consensus Statement on AF Ablation Anticoagulation mgt pre ablation

  • If >48 hrs AF at time of ablation follow DCR guidelines

– ie. TEE or 3 weeks prior anticoagulation

  • TEE in pts in SR may be considered but is not

mandatory

  • Catheter ablation of AF during therapeutic warfarin

anticoagulation should be considered

Calkins HR 2012

2012 HRS/EHRA/ECAS Expert Consensus Statement on AF Ablation Anticoagulation mgt during ablation

  • Heparin prior to or immediately following trans-septal

puncture to achieve and maintain an ACT of 300-400 secs.

  • Intravenous heparin to ACT 300-400 secs should be given

even if pt on warfarin

  • Heparinised saline irrigation of long sheaths

Calkins HR 2012

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SLIDE 4

4 Cerebral Diffusion-Weighted MRI: Monitoring Thrombogenicity of LA Ablation

  • Cerebral MRI pre & post AF ablation (irrigated tip)
  • 2/20 pts (10%) with new MRI lesion
  • No neurological sequelae

1 day post-AF RFA 3 mths post-AF RFA

Lickfett JCE 2006

AF Ablation: A Cause of Silent Embolism?

Open irrigated RF for AF 232 procedures PVI 47% PVI + linear 37% PVI + linear + CFAE 16% Procedure duration 182 mins RF time 46 mins Mean ACT 281 secs ACT<250; 250-300; >300 18%; 57%; 25% SR; SR with RFA; SR with DCR 48%; 25%; 27%

Gaita, Circ 2010

  • 232 consecutive pts pre & post AF ablation MRI
  • New embolic lesions 33 pts (14%)
  • Lesion number: 25 pts- 1 ; 3 pts - 2; 5 pts – 3
  • Lesion size: 3 to 35 mm diameter.
  • No clinical parameters predictive

– age, HT, DM, prior stroke, AF type, pre-RF antithrombotics

  • Procedural parameters were predictive

– ACT – DCR (Rel Risk 2.75; p=0.009)

Gaita, Circ 2010

AF Ablation: A Cause of Silent Embolism?

Relation of DCR and ACT to incidence

  • f silent emboli

DCR RF reversion SR throughout Embolic rate 26% 14% 9%

Gaita, Circ 2010

ACT <250 ACT >250 Silent Emboli incidence 17% 9% Emboli DCR pts 29% 21% Emboli No DCR pts 13% 4%

No silent emboli observed in 65 PeAF pts undergoing DCR alone

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SLIDE 5

5 Delaying DCR for 4-weeks anticoagulation in persistent AF after ablation to reduce silent cerebral embolism: a single-center pilot study

Delayed DCR if in AF (95 pts) Historical controls: DCR if in AF (95 pts) New MRI lesions 6% 16% (p=0.03) New lesions DCR grp 2/15 (13%) 11/29 (38%)

  • No. of pts involved

4 delayed DCR (11 late spont SR) 29 Early DCR ACT (mean secs) 297±56 268±28 Persistent AF 28% 38%

Pianelli, Gaita. J Cardiovasc Med 2011

MEDAFI-Trial (Micro-emboli during AF RFA)

Neumann, Europace 2011

7.9% 82 pts 7 pts

No cerebral lesion Cerebral lesion

20 variables All seven patients had PAF, low CHADS score, and no pre-existing cerebral MRI abnormalities

Incidence of silent cerebral thromboembolism after AF ablation by technology used

Gaita, JCE 2011

PVAC Irrigation cryo

p=0.002 p=0.5

40 30 20 10

p=0.001

%

38.9 8.3 5.6 108 pts undergoing AF ablation Non-randomized

Asymptomatic Emboli After PVI: Comparison of Different AF Ablation Technologies in a Multicenter Study

Irrigated RF (n=27) Cryoballoon (n=23) PVAC (n=24) Silent emboli 2 (7.4%) 1 (4.3%) 9 (37.5%) Emboli/pt 1 1 2.7 Embolus size (mm) 6 4 6.0 (4.5-8.5)

Herrera-Siklody, JACC 2012

ACT>300 secs; PVI only

Non-randomized

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SLIDE 6

6

New silent MRI lesions after AF ablation: Incidence by ablation modality

n Age ACT RF Cryo PVAC Schrickel, EPace 2010

53 53 >250 11.3%

  • Gaita, Circ 2010

232 58 250- 300 14.2%

  • Neumann EPace 2011

89 46-63 >300 6.8% 8.9%

  • Schwarz HR 2011

21 54 >300 9.5%

  • H Siklody JACC 2011

74 61 >300 7.4% 4.3% 37.5%

Gaita JCE 2011

108 56 >300 8.3% 5.6% 38.9%

Trans-cranial Doppler to Measure Cerebral Microembolic Signals During PV Isolation:

Comparison of 3 RF Techniques

500 1000 1500 2000 2500 3000 3500 4000 4500

MES total Ablation period Manipulation period

Solid tip Irrigated RF Cryoballoon

Sauren, JCE 2009 p=0.001 p=0.001 p=0.027

Post-RF asymptomatic cerebral lesions: Long-term follow-up using MRI imaging

Deneke, Heart Rhythm 2011

MRI D1 post ablation

5 small, 1 large lesion

MRI 2 mths post ablation

5 small lesions no longer visible

Post-RF asymptomatic cerebral lesions: Long-term follow-up using MRI imaging

  • 86 pts having AF ablation
  • 84% with PVAC
  • 33/86 pts (38%) had new cerebral lesions

– 30/33 (91% PVAC)

  • 14/33 (42%) had repeat late MRI (2 wks-1yr)
  • These 14 pts

– 50 lesions @ D1 (3.6 lesions/pt) – 3 lesions @ late repeat MRI

Deneke, Heart Rhythm 2011

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SLIDE 7

7

Post-RF asymptomatic cerebral lesions: Lesion size

Deneke, Heart Rhythm 2011

Cardiac surgery incidence of new silent MRI lesions

n New lesions Surgery

Bendszus, 2002 35 26% On pump CABG Restreppo, 2002 13 31% On pump CABG Knipp 2004 29 45% On pump CABG Djaiani, 2004 50 16% On pump CABG Stolz, 2004 37 38% AVR Knipp, 2005 30 47% Valve Friday, 2005 16 31% Off pump CABG Floyd, 2006 34 18% Valve & CABG Cook, 2006 50 32% Valve & CABG Barber, 2008 40 43% Valve & CABG Gerriets, 2010 86 15% On pump CABG

TOTAL 446 29%

Neurocognitive abnormalities and micro- emboli in other cardiac procedures

  • CAB Surgery Newman. NEJM 2001;344:395-402

– 40% POCD > 5yrs post surgery Bladin. Stroke 1998;29:2367-70

  • Valve surgery Pugsley. Stroke 1994;25:1393-99

– 50-97% incidence micro-emboli with mechanical valve – 23% POCD<1 mth post surgery

  • Left heart catheterisation

– Asymptomatic microembolism in >50% pts – 16.7% POCD 24 hours post procedure

AF is independently associated with senile, vascular, & Alzheimer’s dementia

  • 37,025 pts mean age 60.6 yrs
  • 5 yr follow-up

– 27% AF – 4.1% Dementia

  • Dementia risk assocd with:

– Age, HT, CAD, CHF, Prior CVA

  • AF independently assocd with Dementia

Bunch, Heart Rhythm 2010

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SLIDE 8

8

AF is independently associated with senile, vascular, & Alzheimer’s dementia

Bunch, Heart Rhythm 2010

AF is independently assocd with senile, vascular, & Alzheimer’s dementia

Bunch, HR 2010

Highest rel risk in younger age group

AF in stroke-free pts: associated with memory impairment & hippocampal atrophy

Mean performance - Learning & Memory Hippocampal volume

Knecht, European Ht J. 2008

MEDAFI-Trial (Micro-emboli during AF RFA) Incidence of pre-existing MRI lesions

RF (n=44) Cryo (n=45) P Pre-existing MRI lesions 15.9% 8.9% ns Age 58 56 ns PAF 61% 100% <0.001 CHADS2≥2 11% 2% ns CHF 11% 2% ns HT 59% 51% ns Warfarin 59% 42% ns

Neumann, Europace 2011

slide-9
SLIDE 9

9 Neurocognitive decline after AF ablation

  • 23 AF ablation pts

– Cryo 9, RF 13, both 1

  • 23 controls

– No ablation, no AF

  • 3/21 pts (14.3%) new

MRI ischemic lesions

Schwarz et al, Heart Rhythm 2011

Verbal memory pre & 3 mths post RF

Control grp Ablation grp

Neurocognitive decline after AF ablation?

  • 150 patients:
  • AF ablation-90 patients undergoing AF ablation

60 paroxysmal AF; 30 persistent AF

  • SVT ablation - 30 patients

AVNRT=14; AVRT=7; Atc=5; Multiple=4

  • Control population - 30 patients awaiting AF RFA

Non-procedural control group

Medi, Heart Rhythm 2012

Methods: Neurocognitive Testing

  • Standard battery of 8 tests based on Canadian Study of Health

and Aging, evaluating 5 cognitive domains1:

  • Testing administered at 3 timepoints:
  • 1. Baseline: within 7 days prior to RFA
  • 2. Early post-procedure(D2): 24-48hrs post-procedure
  • 3. Late post-procedure(D90): 3 months post-procedure

*Non-procedural controls tested at same timepoints after baseline tests

1Silbert et al. Anaesthesiology 2006;104: 1137-45.

Prevalence of Neuro-cognitive Dysfunction Post AF ablation

p=0.04 p=0.007

% pts

Day 2 Day 90

PAF PeAF SVT Control

Medi, Heart Rhythm 2012

PAF PeAF SVT Control

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SLIDE 10

10

Univariate Risk Factors for POCD (D90)

OR 95% CI P LA Access Time (every min increase) 1.15 1.09-1.20 0.03 Age (every 1 yr incr) 1.0 0.96-1.09 0.5 Male 6.1 0.77-48.67 0.09 Cardioversion 1.0 0.71-1.51 0.8 ACT level 1.0 1.0-1.02 0.1

Medi, Heart Rhythm 2012

Conclusions

  • New MRI lesions in 5-10% of pts after AF ablation
  • Incidence of 30-40% with solid electrodes
  • Majority of lesions are small to moderate in size
  • No overt neurological findings
  • However….

– AF associated with MRI lesions and cognitive decline – Neurocognitive abns in 10-20% after AF RFA

Conclusions

  • Therefore…MRI lesions may be “not so silent”
  • Further evaluation:

– Long term significance of lesions – Relnship btn lesions & cognitive function – Approaches to reduce lesion incidence (therapeutic INR?, timing DCR, catheter design…)

  • ??Use of solid electrodes