Characteristics of radiofrequency lesions in patients with symptomatic periesophageal vagal nerve injury after pulmonary vein isolation.

Background: Periesophageal vagal nerve injury (PNI) is an unpredictable and serious complication of atrial fibrillation (AF) ablation. We aimed to identify the factors associated with symptomatic PNI. Methods: This study included 1391 patients who underwent ablation index-guided pulmonary vein isolation (PVI) using the CARTO system. The target ablation index was set at 550, except for the left atrial (LA) posterior wall near the esophagus, where radiofrequency (RF) power and duration were limited. Ten patients (0.72%) were diagnosed with symptomatic PNI. We randomly selected 40 patients without PNI (1:4 ratio) matched based on age, sex, body mass index, LA diameter, type of AF, and esophageal location. We measured the shortest distance from the RF lesions to the esophagus (LED) and classified the RF lesions according to the LED into four groups: 0-5, 5-10, 10-15, and 15-20 mm. We conducted a comparative analysis of classified RF lesions between patients with PNI (n = 10) and those without (n = 40). Results: The contact force at LED 0-5 mm was significantly higher in patients with PNI than in those without (14.6 ± 1.7 vs. 12.0 ± 2.9 g; p = .01). Multivariate logistic analysis revealed that the independent factor for PNI was contact force at an LED of 0-5 mm (odds ratio: 1.506; 95% confidence interval: 1.053-2.153; p = .025). Conclusions: The symptomatic PNI was significantly associated with a higher contact force near the esophagus. Strategies for regulating contact force near the esophagus may aid in the prevention of PNI.

The optimal slow pathway ablation site in atrioventricular nodal reentrant tachycardia cases with an inferiorly located His bundle.

INTRODUCTION: The optimal slow pathway (SP) ablation site in cases with an inferiorly located His bundle (HIS) remains unclear. METHODS AND RESULTS: In 45 patients with atrioventricular nodal reentrant tachycardia, the relationship between the HIS location and successful SP ablation site was assessed in electroanatomical maps. We assessed the location of the SP ablation site relative to the bottom of the coronary sinus ostium in the superior-to-inferior (SPSI), anterior-to-posterior (SPAP), and right-to-left (SPRL) directions. The HIS location was assessed in the same manner. The HIS location in the superior-to-inferior direction (HISSI), SPSI, SPAP, and SPRL were 17.7 ± 6.4, 1.7 ± 6.4, 13.6 ± 12.3, and -1.0 ± 13.0 mm, respectively. The HISSI was positively correlated with SPSI (R2 = 0.62; P < .01) and SPAP (R2 = 0.22; P < .01), whereas it was not correlated with SPRL (R2 = 0.01; P = .65). The distance between the HIS and SP ablation site was 17.7 ± 6.4 mm and was not affected by the location of HIS. The ratio of the amplitudes of atrial and ventricular potential recorded at the SP ablation site did not differ between the high HIS group (HISSI ≥ 13 mm) and low HIS group (HISSI < 13 mm) (0.10 ± 0.06 vs. 0.10 ± 0.06; P = .38). CONCLUSION: In cases with an inferiorly located HIS, SP ablation should be performed at a lower and more posterior site than in typical cases.

Incidence, distribution, and electrogram characteristics of endocardial-epicardial connections identified by ultra-high-resolution mapping during a left atrial posterior wall isolation of atrial fibrillation.

PURPOSE: The left atrial posterior wall (LAPW) can be a target for atrial fibrillation (AF) catheter ablation but is sometimes difficult to completely isolate due to the presence of endocardial-epicardial connections. We aimed to investigate the incidence and distribution of epicardial residual connections (epi-RCs) and the electrogram characteristics at epi-RC sites during an initial LAPW isolation. METHODS: We retrospectively studied 102 AF patients who underwent LAPW mapping before and after a first-pass linear ablation along the superior and inferior LAPW (pre-ablation and post-ablation maps) using an ultra-high-resolution mapping system (Rhythmia, Boston Scientific). RESULTS: Epi-RCs were observed in 41 patients (40.2%) and were widely distributed in the middle LAPW area and surrounding it. The sites with epi-RCs had a higher bipolar voltage amplitude and greater number of fractionated components than those without (median, 1.09 mV vs. 0.83 mV and 3.9 vs. 3.4 on the pre-ablation map and 0.38 mV vs. 0.27 mV and 8.5 vs. 4.2 on the post-ablation map, respectively; P < 0.001). Receiver operating characteristic analyses demonstrated that the number of fractionated components on the post-ablation map had a larger area under the curve of 0.847 than the others, and the sensitivity and specificity for predicting epi-RCs were 95.4% and 62.1%, respectively, at an optimal cutoff of 5.0. CONCLUSIONS: Among the patients with epi-RCs after a first-pass LAPW linear ablation, areas with a greater number of fractionated components (> 5.0 on the post-ablation LAPW map) may have endocardial-epicardial connections and may be potential targets for touch-up ablation to eliminate the epi-RCs.

Noncontact Charge Density Mapping-Guided Ablation of Persistent Atrial Fibrillation With a Multiple Trigger-Based Mechanism.

We present a case of radiofrequency catheter ablation of persistent atrial fibrillation (AF) with a trigger-based mechanism, guided by novel noncontact charge density mapping, which resulted in the simultaneous achievement of the termination of AF and complete elimination of multiple triggers that induced repeated recurrences of AF immediately after cardioversion. (Level of Difficulty: Advanced.).

Unusual QRS complexes associated with the simultaneous presence of a right-sided accessory pathway, fasciculoventricular pathway, and incomplete right bundle branch block.

A 52-year-old man presented with delta waves on a body surface electrocardiogram, which suggested the presence of a right-sided accessory pathway (AP). Patients with right-sided APs generally have an rS pattern in leads V1-2, while he had an rS in lead V1 but an Rs in lead V2, which could not rule out the possibility of the presence of a septal AP or fasciculoventricular pathway (FVP). On the other hand, patients with septal APs or FVPs generally have a QS pattern in lead V1 instead of an rS pattern. An electrophysiological study demonstrated that the simultaneous presence of a right-sided posterolateral AP and FVP with incomplete right bundle branch block (ICRBBB) generated those unusual QRS complexes. The FVP arose distal to the site with ICRBBB, and the ICRBBB delayed the initiation of the FVP conduction. The delayed QS and Rs waves in leads V1-2 generated by the FVP conduction with ICRBBB appeared to produce rS and Rs patterns in leads V1-2, respectively. A radiofrequency application along the posterolateral tricuspid annulus eliminated the right-sided AP conduction. If the localization of APs based on the QRS morphology is difficult, multiple APs or an FVP with a conduction system disturbance should be noted. Learning objective: Patients with right-sided posterolateral accessory pathways (APs) generally have an rS pattern in lead V2, while patients with fasciculoventricular pathways (FVPs) generally have a QS pattern in lead V1. The present case with a suspected right-sided posterolateral AP had unusual QRS complexes, an rS in lead V1, Rs in lead V2, and monophasic R in leads V3-6, which were associated with the simultaneous presence of a right-sided posterolateral AP, FVP, and incomplete right bundle branch block.

Bilateral Cardiac Sympathetic Denervation for Treatment-Resistant Ventricular Arrhythmias in Heart Failure Patients with a Reduced Ejection Fraction.

The sympathetic nervous system plays an important role in life-threatening ventricular arrhythmias (VAs). Bilateral cardiac sympathetic denervation (BCSD) is performed for refractory VAs. We sought to assess our institutional experience with BCSD in managing treatment-resistant monomorphic ventricular tachycardia (MMVT) in heart failure patients with a reduced ejection fraction (HFrEF).Four patients with HFrEF (EF 30.0 ± 8.2%, New York Heart Association [NYHA] class IV 1) underwent BCSD for MMVT (VT storm 3, repetitive VT requiring implantable cardioverter defibrillator [ICD] therapy 1) refractory to antiarrhythmic drugs, catheter ablation and ICD therapy. BCSD was effective for suppressing VT in 3 patients for whom deep sedation was effective for suppressing VT. One patient remained alive after 14 months of follow-up without episodes of VT. One patient died of acute myocardial infarction before discharge and 1 patient died from unknown cause at 3 days post-discharge. In contrast, BCSD was completely ineffective for suppressing VT in a patient with NYHA class IV for whom deep sedation and stellate ganglion block were ineffective. This patient died on the 10th post-CSD day, despite left ventricular assist device implantation. In all cases, BCSD was successfully performed without procedure-related complications.Despite the limited number of cases, our results showed that BCSD in patients with HFrEF suppressed refractory MMVT in acute-phase except for a patient with NYHA class IV; however, the prognoses were not good. BCSD may be a treatment option at an earlier stage of NYHA and a bridge to orthotopic heart transplantation, even if BCSD is effective for suppressing VAs.

Local impedance measurements during contact force-guided cavotricuspid isthmus ablation for predicting an effective radiofrequency ablation.

Background: An ablation catheter capable of contact force (CF) and local impedance (LI) monitoring (IntellaNav StablePoint, Boston Scientific) has been recently launched. We evaluated the relationship between the CF and LI values during radiofrequency catheter ablation (RFCA) along the cavotricuspid isthmus (CTI). Methods: Fifty consecutive subjects who underwent a CTI-RFCA using IntellaNav StablePoint catheters were retrospectively studied. The initial CF and LI at the start of the RF applications and mean CF and minimum LI during the RF applications were measured. The absolute and percentage LI drops were calculated as the difference between the initial and minimum LIs and 100 × absolute LI drop/initial LI, respectively. Results: We analyzed 602 first-pass RF applications. A weak correlation was observed between the initial CF and LI (r = 0.13) and between the mean CF and LI drops (r = 0.22). The initial LI and absolute and percentage LI drops were greater at effective ablation sites than ineffective ablation sites (median, 151 vs. 138 Ω, 22 vs. 14 Ω, and 14.4% vs. 9.9%; p < .001), but the initial and mean CF did not differ. At optimal cutoffs of 21 Ω and 10.8% for the absolute and percentage LI drops according to the receiver-operating characteristic analysis, the sensitivity, and specificity for predicting an effective ablation were 57.4% and 88.9% and 80.0%, and 61.1%, respectively. Conclusions: The effective sites during the CF-guided CTI-RFCA had greater initial LI and LI drops than the ineffective sites. Absolute and percentage LI drops of 21 Ω and 10.8% may be appropriate targets for an effective ablation.

Symptomatic and asymptomatic intracerebral hemorrhages detected by magnetic resonance imaging after catheter ablation of atrial fibrillation.

PURPOSE: Symptomatic intracerebral hemorrhages (ICHs) are a rare complication after atrial fibrillation (AF) catheter ablation, while the incidence of asymptomatic ICHs detected by magnetic resonance (MR) imaging remains unclear. This study aimed to investigate the incidence, characteristics, and predictors of new-onset ICHs on MR imaging after AF ablation. METHODS: We retrospectively studied 1257 consecutive AF ablation procedures in 1201 patients who underwent MR imaging on the day after the procedure. Repeat MR imaging within 3 months post-ablation was available in 352 procedures. RESULTS: Old ICHs on the initial MR imaging were observed in 28 procedures (2.2%). Post-ablation new ICHs were observed in 14 procedures (4.0%), including one symptomatic (0.3%) and 13 (3.7%) asymptomatic ICHs. One patient had a new ICH on the initial MR imaging, while the remaining 13 had such on the repeat MR imaging. A univariate analysis revealed that a previous ischemic stroke or transient ischemic attack (TIA) and the CHA2DS2-VASc score were positive predictors of new ICHs (odds ratios, 5.502 and 1.435; P = 0.004 and 0.044). The lesion diameter did not significantly differ between the old and new ICHs (median, 6.1 mm vs. 8.0 mm, P = 0.281), while the predominant location differed (lobar areas, 22.6% vs. 53.3%; cerebellum, 22.6% vs. 20.0%; others, 54.8% vs. 26.7%; P = 0.026). CONCLUSIONS: A few asymptomatic ICHs may occur after AF ablation. Most of the post-ablation new ICHs occurred a few days or later after the procedure. A previous ischemic stroke/TIA and the CHA2DS2-VASc score may be risk factors for post-ablation ICHs.

Prevalence, characteristics, and predictors of endocardial and nonendocardial conduction gaps during local impedance-guided extensive pulmonary vein isolation of atrial fibrillation with high-resolution mapping.

INTRODUCTION: Local impedance (LI) drops during radiofrequency ablation can predict lesion formation. Some conduction gaps during pulmonary vein isolation (PVI) can be associated with nonendocardial connections. This study aimed to investigate the incidence, characteristics, and predictors of endocardial and nonendocardial conduction gaps during an LI-guided PVI. METHODS AND RESULTS: We prospectively enrolled 157 consecutive patients undergoing an initial LI-guided extensive PVI of atrial fibrillation (AF). After the first-pass encirclement, the residual conduction gaps and reconnected gaps were mapped using Rhythmia (Boston Scientific) and a mini-basket catheter. Right and left PV (RPV/LPV) gaps were observed in 22.3% and 18.5% of the patients, respectively: 27 endocardial and 49 nonendocardial gaps. The carina regions were common sites for the gaps (51 carina-related vs. 25 noncarina-related). The carina-related gaps consisted of more nonendocardial gaps than endocardial gaps (RPVs: 90.0% vs. 10.0%, p = .001; LPVs: 76.2% vs. 23.8%, p < .001). A univariate analysis revealed that paroxysmal AF and the left atrial (LA) volume index for RPV endocardial gaps (odds ratio [OR]: 8.640 and 0.946; p = .043 and 0.009), minor right inferior PV diameter for RPV nonendocardial gaps (OR: 1.165; p = .028), and major left inferior PV diameter for LPV endocardial gaps (OR: 1.233; p = .028) were significant predictors. CONCLUSIONS: During the LI-guided PVI, approximately two-thirds of the conduction gaps were nonendocardial. The carina regions had more conduction gaps than noncarina regions, which was due to the presence of nonendocardial connections. Paroxysmal AF, a lower LA volume index, and larger inferior PV diameters may increase the risk of conduction gaps.

The prevalence and characteristics of candidates for percutaneous left atrial appendage occlusion using a WATCHMAN device among patients who underwent atrial fibrillation ablation in a Japanese population.

BACKGROUND: Percutaneous left atrial appendage occlusion (LAAO) using a WATCHMAN device could be a treatment option for patients with non-valvular atrial fibrillation (AF) with thromboembolic and bleeding risk. We sought to determine the prevalence and characteristics of patients with AF ablation who are potential candidates for WATCHMAN implantation in a Japanese population. METHODS: We enrolled 2443 consecutive patients who had previously undergone AF ablation and transesophageal echocardiography (TEE). We assessed their clinical characteristics and measured their LAA orifice diameter and depth retrospectively using the obtained TEE images. We defined patients who met both anatomical criteria (LAA orifice max diameter: 17-31 mm and LAA max depth > LAA orifice max diameter) and clinical criteria (CHA2DS2-VASc score ≥ 2 and HAS-BLED score ≥ 3) as LAAO candidates. RESULTS: Among the 2443 enrolled patients, 361 (15%) met the clinical criteria, and 1928 (79%) met the anatomical criteria. Thus 12% (293/2443) of the total patient group met the criteria of LAAO candidates. LAAO candidates showed larger left atrial (LA) volume (77.6 ± 30.1 vs. 67.7 ± 29.1 mL, P < 0.001), larger LAA orifice diameter (22.5 ± 3.2 vs. 22.0 ± 4.3 mm, P = 0.026), and larger LAA depth (28.9 ± 4.6 vs. 27.0 ± 4.8 mm, P < 0.001). LAAO candidates made up only 23% of patients with CHA2DS2-VASc score ≥ 2 (N = 1295), whereas 78% of patients with a HAS-BLED score ≥ 3 (N = 378) were LAAO candidates. CONCLUSION: Twelve percent of patients who underwent AF ablation were potential candidates for LAAO using a WATCHMAN device in this Japanese population. It is imperative to evaluate bleeding risk when considering the indications for LAAO.

Impact of the size of non-ablated left atrial posterior wall area on outcomes after extensive encircling pulmonary vein isolation.

The aim of this study was to evaluate the impact of the size of the isolated surface area and non-ablated left atrial posterior area after extensive encircling pulmonary vein isolation (EEPVI) for non-paroxysmal atrial fibrillation (AF) on arrhythmia recurrence. This study included 132 consecutive persistent AF patients who underwent EEPVI guided by Ablation Index (AI). The isolated antral surface area (IASA) excluding the pulmonary veins, the non-ablated left atrial (LA) posterior wall surface area (PWSA), the ratio of IASA to LA surface area (IASA/LA ratio), and the ratio of PWSA to LA surface area (PWSA/LA ratio) were assessed using CARTO3 and the association with AF and atrial tachycardia (AT) recurrence was examined. At a mean follow-up of 13.2 ± 7.3 months, sinus rhythm was maintained in 115 (87%) patients. In the univariate Cox regression analysis, the factors that significantly predicted AT/AF recurrence were a history of heart failure, a higher CHA2DS2-VASc score, a larger LA diameter, and a larger PWSA/LA ratio. Multivariate Cox regression analysis revealed that the independent predictors of AT/AF recurrence were LA diameter [hazard ratio (HR) 1.120 per 1 mm increase; 95% confidence interval (CI) 1.006-1.247; P = 0.039] and PWSA/LA ratio (HR 1.218 per 1% increase; 95% CI 1.041-1.425; P = 0.014). Receiver operating characteristics curve analysis yielded an optimal cut-off value of 8% for the PWSA/LA ratio. The Kaplan-Meier survival curve showed that patients with a larger PWSA/LA ratio had poorer clinical outcomes (Log-rank P = 0.001). A larger PWSA/LA ratio was associated with a high AT/AF recurrence rate in patients with non-paroxysmal atrial fibrillation.

Hypertrophic Cardiomyopathy Complicated by Cardiac Sarcoidosis Diagnosed by Both the Morphological Abnormalities and the Time Course of the Disease.

The definite diagnosis of cardiac sarcoidosis (CS) can be difficult because it mimics other cardiomyopathies and morphological abnormalities during its time course. Distinguishing CS isolated cardiac sarcoidosis from other cardiomyopathies is very important for the introduction of immunosuppressive therapy.In this study, we report a patient who had initially been diagnosed with hypertrophic obstructive cardiomyopathy (HOCM). The patient developed complete atrioventricular block (CAVB) and morphological abnormalities, which led to his primary diagnosis being re-conducted. Moreover, we made a definite diagnose of isolated CS (ICS) based on the guideline for the diagnosis and treatment using 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT)1) and performed tailor-made treatment including immunosuppressive therapy.

Effect of preventing air intrusion on silent strokes during atrial fibrillation ablation using a mini-basket catheter.

BACKGROUND: Air bubble intrusion through transseptal sheaths during left atrial (LA) catheter ablation can cause cerebral embolisms, especially when using complex-shape catheters. This study aimed to compare the incidence of silent cerebral events (SCEs) after atrial fibrillation (AF) catheter ablation using a mini-basket catheter (IntellaMap Orion; Boston Scientific) between the following groups: group SP, strict prevention of LA air intrusion and group CP, conventional air intrusion prevention. METHODS: We enrolled 123 consecutive AF patients (group SP, n = 61 and group CP, n = 62) who underwent brain magnetic resonance imaging after a local-impedance-guided ablation using one mini-basket catheter and one circular mapping catheter. The preventive strategy in group SP included (a) the insertion of the mini-basket catheter into the transseptal sheaths in a container filled with heparinized saline and (b) no exchange of all catheters over the sheaths. RESULTS: SCEs were detected in 67 patients (54.5%), and the incidence of SCEs did not significantly differ between groups SP and CP (55.7% vs 53.2%; P = .780). A multivariate analysis demonstrated that an older age, non-paroxysmal AF, and radiofrequency (RF) power output were independent positive predictors of SCEs (odds ratios: 1.079, 5.613, and 1.405; P = .005, <.001, and .012). On the follow-up MR imaging, 83.5% of the SCEs in group SP and 87.7% in group CP disappeared (P = .398). CONCLUSIONS: Strict prevention of LA air intrusion may have no additional effect for reducing the incidence of SCEs after local impedance-guided AF ablation using a mini-basket catheter. An older age, non-paroxysmal AF, and high-power RF applications may increase the risk of SCEs.

Incidence and characteristics of silent cerebral embolisms after radiofrequency-based atrial fibrillation ablation: A propensity score-matched analysis between different mapping catheters and indices for guiding ablation.

INTRODUCTION: The difference in the incidence and characteristics of silent cerebral events (SCEs) after radiofrequency-based atrial fibrillation (AF) ablation between the different mapping catheters and indices used for guiding radiofrequency ablation remains unclear. This study aimed to compare the incidence and characteristics of postablation SCEs between the following two groups: Group C, Ablation Index-guided ablation using two circular mapping catheters with CARTO (Biosense Webster); Group R, local impedance-guided ablation using one mini-basket catheter and one circular mapping with Rhythmia (Boston Scientific). METHODS AND RESULTS: Of 211 consecutive patients who underwent an AF ablation and brain magnetic resonance (MR) imaging after the ablation, 120 patients (each group, n = 60) were selected by propensity score matching. SCEs were detected in 37 patients (30.8%). Group R had a higher incidence of SCEs (51.7% vs. 10.0%; p < .001) and more SCEs per patient (median, 3 vs. 1, p = .028) than Group C. A multivariate analysis demonstrated that nonparoxysmal AF and being Group R were independent positive predictors of SCEs (odds ratios, 6.930 and 15.464; both p < .001). On the follow-up MR imaging, all SCEs in Group C and 87.9% of the SCEs in Group R disappeared (p = .537). CONCLUSIONS: Group R had a significantly higher incidence of SCEs than Group C. Most probably the use of a complexly designed basket mapping catheter is the reason for the difference in the incidence of SCEs but further validation is needed. A nonparoxysmal form of AF may also increase the risk of SCEs during these ablation procedures.

Optimal local impedance drops for an effective radiofrequency ablation during cavo-tricuspid isthmus ablation.

PURPOSE: A novel ablation catheter capable of local impedance (LI) monitoring (IntellaNav MiFi OI, Boston Scientific) has been recently introduced to clinical practice. We aimed to determine the optimal LI drops for an effective radiofrequency ablation during cavo-tricuspid isthmus (CTI) ablation. METHODS: This retrospective observational study enrolled 50 consecutive patients (68 ± 9 years; 34 males) who underwent a CTI ablation using the IntellaNav MiFi OI catheter, guided by Rhythmia. The LI at the start of radiofrequency applications (initial LI) and minimum LI during radiofrequency applications were evaluated. The absolute and percentage LI drops were defined as the difference between the initial and minimum LIs and 100× absolute LI drop/initial LI, respectively. RESULTS: A total of 518 radiofrequency applications were analyzed. The absolute and percentage LI drops were significantly greater at effective ablation sites than ineffective sites (median, 15 ohms vs 8 ohms, P < .0001; median, 14.7% vs 8.3%, P < .0001). A receiver-operating characteristic analysis demonstrated that at optimal cutoffs of 12 ohms and 11.6% for the absolute and percentage LI drops, the sensitivity and specificity for predicting the effectiveness of the ablation were 66.5% and 88.2%, and 65.1% and 88.2%, respectively. Finally, bidirectional conduction block along the CTI was achieved in all patients. CONCLUSIONS: During the LI-guided CTI ablation, the effective RF ablation sites exhibited significantly greater absolute and percentage LI drops than the ineffective RF ablation sites. Absolute and percentage LI drops of 12 ohms and 11.6% may be suitable targets for effective ablation.

The effect of bilateral cardiac sympathetic denervation for refractory ventricular tachycardia in ischemic cardiomyopathy.

Recent studies have shown that cardiac sympathetic denervation (CSD) is effective in the treatment of refractory ventricular tachyarrhythmia in patients with structural heart disease. This case report aimed to highlight the effect of bilateral CSD in suppressing treatment-resistant ventricular tachycardia in patients with ischemic cardiomyopathy.

Impact of the type of electroanatomic mapping system on the incidence of cerebral embolism after radiofrequency catheter ablation of left atrial tachycardias.

BACKGROUND: Left atrial tachycardias (ATs) often occur after left atrial ablation. The incidence of symptomatic and silent cerebral embolism after radiofrequency catheter ablation of left ATs and the impact of the type of 3-dimensional electroanatomic mapping (3D-EAM) system on the incidence of cerebral embolism remain unclear. OBJECTIVES: This study aimed to investigate the incidence of cerebral embolism after a 3D-EAM system-guided left AT ablation procedure and compare that between the different 3D-EAM systems. METHODS: We prospectively enrolled 59 patients who underwent left AT ablation and brain magnetic resonance imaging after the procedure: 30 were guided by the Rhythmia system (Boston Scientific, Marlborough, MA) and 29 by the CARTO system (Biosense Webster, Diamond Bar, CA) (groups R and C, respectively). RESULTS: One transient ischemic attack occurred in group R, and no symptomatic embolism occurred in group C. Silent cerebral ischemic lesions (SCILs) were observed in 35 patients (59.3%), and group R had a significantly higher incidence of SCILs than did group C (86.2% vs 33.3%; P < .001). In multivariate analysis, group R and left atrial linear ablation were independent positive predictors of SCILs (odds ratio 12.822 and 8.668; P = .001 and P = .005). The incidence of bleeding complications was comparable between groups R and C (0% vs 3.3%; P = .508). CONCLUSION: Group R exhibited a higher incidence of postablation cerebral embolism than did group C. The use of the high-resolution 3D-EAM system with a mini-basket catheter to guide radiofrequency ablation of left atrial macroreentrant tachycardias may markedly increase the risk of silent cerebral embolism. The present results require further validation in a randomized study.

Postablation cerebral embolisms in balloon-based atrial fibrillation ablation with periprocedural direct oral anticoagulants: A comparison between cryoballoon and HotBalloon ablation.

INTRODUCTION: This prospective observational study aimed to investigate the incidence of symptomatic and silent cerebral embolisms after balloon-based ablation of atrial fibrillation (AF) in patients receiving periprocedural anticoagulation with direct oral anticoagulants (DOACs), and compare that between cryoballoon and HotBalloon ablation (CBA and HBA). METHODS AND RESULTS: We enrolled 123 consecutive AF patients who underwent a balloon-based pulmonary vein isolation (PVI) and brain magnetic resonance (MR) imaging after the ablation procedure (CBA, n = 65; HBA, n = 58). The DOACs were continued in 62 patients throughout the periprocedural period and discontinued in 61 on the procedural day. Intravenous heparin was infused to maintain an activated clotting time of 300 to 400 seconds during the procedure. No symptomatic embolisms occurred in this series. Silent cerebral ischemic lesions (SCILs) were observed on MR imaging in 22 patients (17.9%), and the incidence of SCILs did not significantly differ between the CBA and HBA groups (21.5 vs 13.8%; P = 0.263). According to a multivariate logistic regression analysis, an older age was an independent positive predictor of SCILs (odds ratio, 1.062; 95% CI, 1.001-1.126; P = 0.046), but neither the balloon catheter type nor periprocedural continuation or discontinuation of the DOACs were significant predictors. The incidence of major and minor bleeding complications was comparable between the CBA and HBA groups (1.5 vs 0%, P = 0.528; 7.7 vs 5.2%, P = 0.424). CONCLUSIONS: Both CBA and HBA of AF revealed a similar incidence of postablation cerebral embolisms. Elderly patients may be at a risk of SCILs after a balloon-based PVI with periprocedural DOAC treatment.