Cerebral thromboembolic events are well-known complications of pulmonary vein isolation (PVI) and can manifest as stroke or silent cerebral embolic lesions. The aim of this study was to compare the incidence of cerebral embolic lesions (including silent cerebral embolism and stroke) after AF ablation in patients on vitamin K antagonists versus patients on non-vitamin K-dependent oral anticoagulants, and to identify corresponding clinical and procedural risk factors.
A total of 421 patients undergoing PVI were prospectively included into the study. Of these, 43.7% were on VKA and 56.3% on NOAC treatment (dabigatran, rivaroxaban, apixaban, and edoxaban). In the NOAC group, 38% of patients had an interruption of anticoagulation for 24–36 h. All patients underwent pre- and postprocedural cerebral magnetic resonance imaging.
Periprocedural cerebral lesions occurred in 13.1% overall. Of these, three (0.7%) resulted in symptomatic cerebrovascular accidents and 52 (12.4%) in silent cerebral embolic lesions. Incidence of cerebral lesions was significantly higher in patients on NOAC compared with VKA (16% vs. 9.2%, respectively, p = 0.04), and in patients who had intraprocedural cardioversions compared with no cardivoersions (19.5% vs. 10.4%, respectively, p = 0.03). In multivariate analysis, both parameters were found to be independent risk factors for cerebral embolism. No significant difference between interrupted and uninterrupted NOAC administration could be detected.
In patients undergoing AF ablation, we identified the use of NOAC and intraprocedural cardioversion as independent risk factors for the occurrence of periprocedural cerebral embolic lesions.
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Calkins H, Hindricks G, Cappato R, Kim Y-H, Saad EB, Aguinaga L, et al. Document Reviewers:. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2018;20(1):e1–160.
Forleo GB, Della Rocca DG, Lavalle C, Mantica M, Papavasileiou LP, Ribatti V, et al. A patient with asymptomatic cerebral lesions during AF ablation: how much should we worry? J Atr Fibrillation. 2016;8(5):1323.
Deneke T, Nentwich K, Krug J, Müller P, Grewe PH, Mügge A, et al. Silent cerebral events after atrial fibrillation ablation-overview and current data. J Atr Fibrillation. 2014;6(5):996.
Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, et al. The 2018 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: executive summary. Europace. 2018;20(8):1231–42.
Ha FJ, Barra S, Brown AJ, Begley DA, Grace AA, Agarwal S. Continuous and minimally-interrupted direct oral anticoagulant are both safe compared with vitamin K antagonist for atrial fibrillation ablation: an updated meta-analysis. Int J Cardiol. 2018;262:51–6.
Hohnloser SH, Camm AJ. Safety and efficacy of dabigatran etexilate during catheter ablation of atrial fibrillation: a meta-analysis of the literature. Europace. 2013;15(10):1407–11.
Di Biase L, Lakkireddy D, Trivedi C, Deneke T, Martinek M, Mohanty S, et al. Feasibility and safety of uninterrupted periprocedural apixaban administration in patients undergoing radiofrequency catheter ablation for atrial fibrillation: results from a multicenter study. Heart Rhythm. 2015;12(6):1162–8.
Cappato R, Marchlinski FE, Hohnloser SH, Naccarelli GV, Xiang J, Wilber DJ, et al. Uninterrupted rivaroxaban vs. uninterrupted vitamin K antagonists for catheter ablation in non-valvular atrial fibrillation. Eur Heart J. 2015;36(28):1805–11.
Hakalahti A, Uusimaa P, Ylitalo K, Raatikainen MJP. Catheter ablation of atrial fibrillation in patients with therapeutic oral anticoagulation treatment. Europace. 2011;13(5):640–5.
Martinek M, Sigmund E, Lemes C, Derndorfer M, Aichinger J, Winter S, et al. Asymptomatic cerebral lesions during pulmonary vein isolation under uninterrupted oral anticoagulation. Europace. 2013;15(3):325–31.
Buist TJ, Adiyaman A, Smit JJJ, Ramdat Misier AR, Elvan A. Arrhythmia-free survival and pulmonary vein reconnection patterns after second-generation cryoballoon and contact-force radiofrequency pulmonary vein isolation. Clin Res Cardiol. 2018;107(6):498–506.
Herm J, Schurig J, Martinek MR, Höltgen R, Schirdewan A, Kirchhof P, et al. MRI-detected brain lesions in AF patients without further stroke risk factors undergoing ablation-a retrospective analysis of prospective studies. BMC Cardiovasc Disord. 2019;19(1):58.
Nakamura K, Naito S, Sasaki T, Take Y, Minami K, Kitagawa Y, et al. Uninterrupted vs. interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: a prospective randomized single-centre study on post-ablation thrombo-embolic and haemorrhagic events. Europace. 2019;21(2):259–67.
Nakamura K, Naito S, Sasaki T, Minami K, Take Y, Goto E, et al. Silent cerebral ischemic lesions after catheter ablation of atrial fibrillation in patients on 5 types of periprocedural oral anticoagulation–predictors of diffusion-weighted imaging-positive lesions and follow-up magnetic resonance imaging. Circ J. 2016;80(4):870–7.
Aimo A, Giugliano RP, De Caterina R. Non–vitamin K antagonist oral anticoagulants for mechanical heart valves. Circulation. 2018;138(13):1356–65.
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893–962.
Briceno DF, Villablanca PA, Lupercio F, Kargoli F, Jagannath A, Londono A, et al. Clinical impact of heparin kinetics during catheter ablation of atrial fibrillation: meta-analysis and meta-regression. J Cardiovasc Electrophysiol. 2016;27(6):683–93.
Gaita F, Caponi D, Pianelli M, Scaglione M, Toso E, Cesarani F, et al. Radiofrequency catheter ablation of atrial fibrillation: a cause of silent thromboembolism? Circulation. 2010;122(17):1667–73.
Scaglione M, Blandino A, Raimondo C, Caponi D, Di Donna P, Toso E, 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(8):801–5.
Doi A, Takagi M, Kakihara J, Hayashi Y, Tatsumi H, Fujimoto K, et al. Incidence and predictors of silent cerebral thromboembolic lesions after catheter ablation for atrial fibrillation in patients treated with direct oral anticoagulants. Heart Vessel. 2017;32(10):1227–35.
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed were in accordance with the ethical standards of the national research committee (Ethikkommission des Landes Oberösterreich (Ethics Commission of the State of Upper Austria), ethics committee vote reference number K-103-16) and with the 1964 Helsinki declaration and its later amendments.
Informed consent was obtained from all individual participants included in the study.
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Petzl, A., Derndorfer, M., Kollias, G. et al. Cerebral thromboembolic risk in atrial fibrillation ablation: a direct comparison of vitamin K antagonists versus non-vitamin K-dependent oral anticoagulants. J Interv Card Electrophysiol 60, 147–154 (2021). https://doi.org/10.1007/s10840-020-00718-w
- Atrial fibrillation ablation
- Non-vitamin K-dependent oral anticoagulant
- Vitamin K antagonist
- Silent cerebral embolism
- Cerebral magnetic resonance imaging