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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Brain Emboli After Left Ventricular Endocardial Ablation
Isaac R Whitman1, Rachel A Gladstone1, Nitish Badhwar1
1From Electrophysiology Section, Division of Cardiology, University of California, San Francisco (I.R.W., R.A.G., N.B., H.H.H., B.K.L., E.P.G., G.M.M.); Department of Neurology, University of California, San Francisco (S.A.J., K.M.M., W.P.D., C.P.H.); and Division of Neuroradiology, Department of Radiology, University of California, San Francisco (W.P.D., C.P.H.).
Insights
Left ventricular ablation for ventricular tachycardia and premature ventricular complexes (PVCs) is linked to a high risk of cerebral emboli. Further research is needed to understand and prevent these post-ablation brain lesions.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Catheter ablation is a common treatment for ventricular tachycardia and premature ventricular complexes (PVCs).
- Cerebral emboli are a known risk in atrial fibrillation ablation but not well-studied in ventricular ablation.
- Understanding embolic risk in ventricular ablation is crucial for patient safety.
Purpose of the Study:
- To evaluate the incidence of cerebral emboli following catheter ablation for ventricular tachycardia and PVCs.
- To compare embolic risk between left ventricular (LV) and right ventricular ablation procedures.
- To identify potential risk factors for cerebral emboli in ventricular ablation.
Main Methods:
- 18 consecutive patients undergoing ventricular ablation were enrolled.
- Patients were divided into left ventricular (LV) ablation and right ventricular ablation groups.
- Pre- and postprocedural brain MRI was used to detect embolic infarcts.
Main Results:
- 58% of patients undergoing LV ablation experienced cerebral emboli (16 total).
- No cerebral emboli were observed in patients undergoing right ventricular ablation (P=0.04).
- 63% of patients with a retrograde LV approach developed new brain lesions.
Conclusions:
- Routine left ventricular ablation procedures are associated with a high incidence of new brain emboli.
- The findings highlight the need for further research into the long-term effects and prevention strategies for these lesions.
- Cerebral embolic risk appears significantly lower in right ventricular ablation compared to left ventricular ablation.
Background:
Catheter ablation for ventricular tachycardia and premature ventricular complexes (PVCs) is common. Catheter ablation of atrial fibrillation is associated with a risk of cerebral emboli attributed to cardioversions and numerous ablation lesions in the low-flow left atrium, but cerebral embolic risk in ventricular ablation has not been evaluated.
Methods:
We enrolled 18 consecutive patients meeting study criteria scheduled for ventricular tachycardia or PVC ablation over a 9-month period. Patients undergoing left ventricular (LV) ablation were compared with a control group of those undergoing right ventricular ablation only. Patients were excluded if they had implantable cardioverter defibrillators or permanent pacemakers. Radiofrequency energy was used for ablation in all cases and heparin was administered with goal-activated clotting times of 300 to 400 seconds for all LV procedures. Pre- and postprocedural brain MRI was performed on each patient within a week of the ablation procedure. Embolic infarcts were defined as new foci of reduced diffusion and high signal intensity on fluid-attenuated inversion recovery brain MRI within a vascular distribution.
Results:
The mean age was 58 years, half of the patients were men, half had a history of hypertension, and the majority had no known vascular disease or heart failure. LV ablation was performed in 12 patients (ventricular tachycardia, n=2; PVC, n=10) and right ventricular ablation was performed exclusively in 6 patients (ventricular tachycardia, n=1; PVC, n=5). Seven patients (58%) undergoing LV ablation experienced a total of 16 cerebral emboli, in comparison with zero patients undergoing right ventricular ablation (P=0.04). Seven of 11 patients (63%) undergoing a retrograde approach to the LV developed at least 1 new brain lesion.
Conclusions:
More than half of patients undergoing routine LV ablation procedures (predominately PVC ablations) experienced new brain emboli after the procedure. Future research is critical to understanding the long-term consequences of these lesions and to determining optimal strategies to avoid them.
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