Search

Few data are available regarding the prevalence of left atrium (LA) thrombi in atrial fibrillation (AF) patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods: We evaluated the prevalence and predictors of LA/LA appendage (LAA) thrombi in non-valvular AF patients treated with NOACs referring to a single centre for a scheduled electrical cardioversion (ECV) or catheter ablation (CA). Transesophageal echocardiography (TEE) was performed within 12 h prior to the index procedure. A total of 352 consecutive patients with non-valvular AF treated with NOACs were included in this analysis (ECV group n = 176 and CA group n = 176) between 2013 and 2018. 85 patients (24.2%) were on dabigatran, 150 (42.7%) on rivaroxaban, 104 (29.6%) on apixaban and 13 (3.7%) on edoxaban. A LA/LAA thrombus was detected by TEE in 27 (7.7%) patients, 18 in the ECV group and nine in the ablation group; 18 (5.1%) patients presented dense LA/LAA spontaneous echo contrast (SEC). Predictors of LA/LAA thrombi were a CHA2DS2-VASc score > 3 (OR 4.54, 95% CI 1.50 − 13.70, p value = .007) and obesity (OR 6.01, 95% CI 1.95 − 18.50, p value = .001). Among real-world patients with non-valvular AF treated with NOACs, we found a high incidence of LA/LAA thrombi compared to previous reports. The main predictors of LA/LAA thrombosis were a CHA2DS2-VASc score > 3 and obesity.

Background and Purpose: Clinical trials on stroke prevention in patients with atrial fibrillation have consistently shown clinical benefit from either warfarin or non–vitamin K antagonist oral anticoagulants (NOACs). NOAC-treated patients have consistently reported to be at lower risk for intracerebral hemorrhage (ICH) than warfarin-treated patients. The aims of this prospective, multicenter, multinational, unmatched, case-control study were (1) to investigate for risk factors that could predict ICH occurring in patients with atrial fibrillation during NOAC treatment and (2) to evaluate the role of CHA 2 DS 2 -VASc and HAS-BLED scores in the same setting. Methods: Cases were consecutive patients with atrial fibrillation who had ICH during NOAC treatment. Controls were consecutive patients with atrial fibrillation who did not have ICH during NOAC treatment. As within the CHA 2 DS 2 -VASc and HAS-BLED scores there are some risk factors in common, several multivariable logistic regression models were performed to identify independent prespecified predictors for ICH events. Results: Four hundred nineteen cases (mean age, 78.8±8.1 years) and 1526 controls (mean age, 76.0±10.3 years) were included in the study. From the different models performed, independent predictors of ICH were increasing age, concomitant use of antiplatelet agents, active malignancy, high risk of fall, hyperlipidemia, low clearance of creatinine, peripheral artery disease, and white matter changes. Low doses of NOACs (given according to label or not) and congestive heart failure were inversely associated with the risk of ICH. HAS-BLED and CHA 2 DS 2 -VASc scores performed poorly in predicting ICH with areas under the curves of 0.496 (95% CI, 0.468–0.525) and 0.530 (95% CI, 0.500–0.560), respectively. Conclusions: Several risk factors were associated to ICH in patients treated with NOACs for stroke prevention but not HAS-BLED and CHA 2 DS 2 -VASc scores.

Background and Purpose— Despite treatment with oral anticoagulants, patients with nonvalvular atrial fibrillation (AF) may experience ischemic cerebrovascular events. The aims of this case-control study in patients with AF were to identify the pathogenesis of and the risk factors for cerebrovascular ischemic events occurring during non–vitamin K antagonist oral anticoagulants (NOACs) therapy for stroke prevention. Methods— Cases were consecutive patients with AF who had acute cerebrovascular ischemic events during NOAC treatment. Controls were consecutive patients with AF who did not have cerebrovascular events during NOACs treatment. Results— Overall, 713 cases (641 ischemic strokes and 72 transient ischemic attacks; median age, 80.0 years; interquartile range, 12; median National Institutes of Health Stroke Scale on admission, 6.0; interquartile range, 10) and 700 controls (median age, 72.0 years; interquartile range, 8) were included in the study. Recurrent stroke was classified as cardioembolic in 455 cases (63.9%) according to the A-S-C-O-D (A, atherosclerosis; S, small vessel disease; C, cardiac pathology; O, other causes; D, dissection) classification. On multivariable analysis, off-label low dose of NOACs (odds ratio [OR], 3.18; 95% CI, 1.95–5.85), atrial enlargement (OR, 6.64; 95% CI, 4.63–9.52), hyperlipidemia (OR, 2.40; 95% CI, 1.83–3.16), and CHA 2 DS 2 -VASc score (OR, 1.72 for each point increase; 95% CI, 1.58–1.88) were associated with ischemic events. Among the CHA 2 DS 2 -VASc components, age was older and presence of diabetes mellitus, congestive heart failure, and history of stroke or transient ischemic attack more common in patients who had acute cerebrovascular ischemic events. Paroxysmal AF was inversely associated with ischemic events (OR, 0.45; 95% CI, 0.33–0.61). Conclusions— In patients with AF treated with NOACs who had a cerebrovascular event, mostly but not exclusively of cardioembolic pathogenesis, off-label low dose, atrial enlargement, hyperlipidemia, and high CHA 2 DS 2 -VASc score were associated with increased risk of cerebrovascular events.

Background: In recent years, direct-acting oral anticoagulants (DOACs) have entered clinical practice for stroke prevention in non-valvular atrial fibrillation or prevention and treatment of venous thromboembolism. However, remaining uncertainty regarding DOAC use in some clinical scenarios commonly encountered in the real world has not been fully explored in clinical trials. Methods: We report on use of a Delphi consensus process on DOAC use in non-valvular atrial fibrillation patients. The consensus process dealt with 9 main topics: (i) DOACs vs vitamin K antagonists in atrial fibrillation (AF) patients; (ii) therapeutic options for patients with stable total time in range treated with vitamin K antagonists; (iii) therapeutic options for patients aged > 85 years; (iv) therapeutic management of hyperfiltering patients; (v) pharmacologic interactions; (vi) therapeutic options in the long-term treatment (prevention) of patients with AF and acute coronary syndrome after the triple therapy; (vii) low doses of DOACs in AF patients; (viii) ischemic stroke in patients inappropriately treated with low doses of DOACs; (ix) management of patients taking DOACs with left atrial appendage thrombosis. Results: A total of 101 physicians (cardiologists, internists, geriatricians, and hematologists) from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = somewhat agree; 4 = agree; 5 = strongly agree). Votes 1-2 were considered to be disagreement; votes 3-5 were considered to be agreement. Agreement among the respondents of ≥ 66% for each statement was considered consensus. A brief discussion of the results for each topic is also reported. Conclusions: In clinical practice, there is still uncertainty on DOAC use, especially in elderly, fragile, comorbid, and hyperfiltering patients. Résumé: Contexte: Depuis quelques années, les cliniciens prescrivent des anticoagulants oraux directs (AOD) pour prévenir les accidents vasculaires cérébraux (AVC) chez les patients présentant une fibrillation auriculaire (FA) non valvulaire ou pour prévenir et traiter les thromboembolies veineuses. Cependant, les doutes que suscite encore l’emploi des AOD dans certains contextes courants de la pratique clinique n’ont pas encore été bien explorés dans le cadre des études cliniques. Méthodologie: Nous avons utilisé la méthode de Delphes, une démarche visant à dégager un consensus, afin d’évaluer le recours aux AOD chez des patients présentant une FA non valvulaire. L’étude comprenait 9 thèmes principaux : i) utilisation des AOD et des antagonistes de la vitamine K chez les patients présentant une FA; ii) options thérapeutiques pour les patients traités par un antagoniste de la vitamine K dont l’état se maintient depuis un certain temps dans une plage de valeurs normales; iii) options thérapeutiques pour les patients âgés de plus de 85 ans; iv) prise en charge thérapeutique des patients souffrant d’hyperfiltration; v) interactions pharmacologiques; vi) options thérapeutiques pour le traitement prolongé (préventif) des patients présentant une FA et un syndrome coronarien aigu après une trithérapie; vii) utilisation des AOD à faible dose chez les patients présentant une FA; viii) AVC ischémique chez les patients traités de façon inappropriée par un AOD à faible dose; ix) prise en charge des patients prenant un AOD qui présentent une thrombose de l’appendice auriculaire gauche. Résultats: Au total, 101 médecins (cardiologues, internistes, gériatres et hématologues) italiens ont exprimé leur degré d’accord avec chacun des énoncés proposés sur une échelle de Likert à 5 points (1 = tout à fait en désaccord; 2 = en désaccord; 3 = moyennement d’accord; 4 = d’accord; 5 = tout à fait d’accord). Une note de 1 ou 2 a été considérée comme un désaccord et une note de 3, 4 ou 5, comme un accord. On considérait qu’il y avait un consensus si 66 % ou plus des répondants étaient d’accord avec l’énoncé. Nous présentons également brièvement les résultats obtenus pour chacun des thèmes. Conclusions: Dans la pratique clinique, l’emploi des AOD soulève encore des doutes, en particulier chez les patients âgés, fragiles ou présentant des affections concomitantes ou une hyperfiltration.

Introduction Anticoagulantion therapy (OAT) represents the cornerstone to reduce thromboembolic events for atrial fibrillation (AF). Recent studies suggest that AF catheter ablation on top of OAT may be useful to further reduce the thromboembolic risk in AF patients. The aim of the present study is to compare the long-term risk of thromboembolic events and treatment-related complications in patients with AF treated by OAT strategies and catheter ablation. Methods Pubmed, Cochrane and Google Scholar were searched for studies including >500 patients evaluating AF patients treated with OAT (VKA: vitamin K antagonist or DOAC: Direct oral anticoagulants) and/or AF ablation. Pooled incidence of stroke/year was the primary end point, while that of stroke, of all cause bleeding and of major bleeding the secondary ones. All the analyses were stratified according to the CHADS 2 score of included patients. Results Overall, 27 studies were selected, including 50,973 patients in the AF catheter ablation group; 281,595 patients in the VKA group; 54,811 patients in the DOAC group. After a mean follow-up of 2.4 (1.5–3.8) years, the overall incidence of stroke and thromboembolic events was 0.63 per 100 patients/year in AF ablation group, 2.09 per 100 patients/year in VKA group and 1.24 per 100 patients/year in DOAC group ( p 2 score, the incidence of thromboembolic events remained lower in patients included in the AF ablation, followed by DOAC and VKA respectively ( p 2 cluster. Both the incidence of all cause bleedings and major bleedings resulted lower in AF ablation group ( p p Conclusion AF catheter ablation significantly reduces the incidence of long-term thromboembolic events compared to both VKA and DOAC. This reduction is maintained in all CHADS 2 score clusters and is strengthened by the concomitant reduction in hemorrhagic complications provided by AF ablation.

Aims Despite optimal oral anticoagulation with vitamin K antagonist, left atrial (LA) thrombus could be detected in the left appendage (LAA) in >2% of patients with atrial fibrillation (AF) and CHA 2 DS 2 -VASc score≥1 but few data are available for patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). We evaluated the occurrence and predictors of LA thrombi by means of transesophageal echocardiography (TOE) in consecutive patients with non-valvular AF who received for at least 3weeks Apixaban, Dabigatran, or Rivaroxaban. Methods This study included 414 consecutive patients (male 252, 60.6%, mean age 67.3years) referred to our Centers for catheter ablation of AF (n=220, 53.1%) or scheduled electrical cardioversion (n=194, 46.9%). Patients were on Dabigatran (n=160), Rivaroxaban (n=150) or Apixaban (n=104). TOE was performed in all cases within 12h prior to ablation or cardioversion. Results Preprocedural TOE revealed LA thrombus in 15/414 patients (3.6%), all located in the LAA (Apixaban 3/104 2.9%, Dabigatran 5/160 3.1%, and Rivaroxaban 7/150 4.7%, p=0.69). Of these, 14 patients had persistent AF. Patients with LAA thrombus had a mean CHA 2 DS 2 -VASc score of 3 (3–4). Higher CHA 2 DS 2 -VASc score (p=0.02), but not the type of NOAC, significantly predicted the presence of LA thrombus. Conclusion The incidence of LAA thrombus in a cohort of patients anticoagulated with NOACs is low but not negligible, in any case similar among the 3 drugs. Preprocedural TOE should be considered in patients with a CHA 2 DS 2 -VASc score>3.

Aim of this study is to evaluate the impact of antiarrhythmic drugs (AADs) administration for at least one month before ECV on the acute and long term success rate of the procedure.1313 consecutive persistent AF patients were enrolled in 3 different centers (Turin, Asti and Avellino): 692 patients received AADs before and after ECV (group A), 621 patients were treated only after the procedure, at discharge (group B). Primary end point was the restoration and maintenance of sinus rhythm acutely and at a long-term follow up.Acute ECV success was higher in group A compared with group B (99% vs. 88%, p=0.0001) and a fewer number of shock attempts were administered (1.15±0.42 vs. 1.27±0.53 p0.0001). Moreover group A maintained SR more often than group B at one month (99% vs. 89%, log-rank p0.0001), at one year (55% vs. 48% log-rank p=0.01) and at the end of follow up (mean 2.7±2.1years, 45% vs. 29%, log-rank p0.0001). At multivariate analysis AADs premedication was the strongest independent predictor of acute and long-term ECV success (respectively p0.0001 OR 10.71 CI 5.10-22.50 and p=0.004, OR 1.50 CI 1.14-1.97). At sensitivity analysis no differences were found between ADDs in terms of acute success improvement (p=0.605), number of shock attempts (p=0.853) and long term SR maintenance (log-rank p=0.480).AADs administration for at least 4weeks before the ECV in persistent AF increases significantly the acute success rate and this result was maintained over a long-term follow-up.

Aims Net clinical benefit of long-term oral anticoagulation therapy (OAT) continuation after successful atrial fibrillation (AF) ablation is still controversial. To evaluate long-term thromboembolic (TE) and haemorrhagic events incidence according to OAT strategy used after AF transcatheter ablation. Methods and results Three months after AF ablation, OAT was discontinued in patients with CHADS2 ≤ 1 if no recurrences were documented, while OAT was maintained in patients with CHADS2 ≥ 2 regardless of AF recurrences. CHA2DS2VASc and HAS-BLED scores have been retrospectively evaluated. Seven hundred and sixty-six patients were followed for a median of 60.5 months. Six (6/267 = 2.2%) and five (5/499 = 1%) TE events occurred in the ON and the OFF-OAT patients, respectively ( P = 0.145), all in concomitance with the AF recurrence. CHADS2 and CHA2DS2VASc ≥ 2 were associated with high TE incidence ( P = 0.047 and P = 0.020). Among patients with a CHADS2 score of 0 or 1, a CHA2DS2VASc score ≥ 2 was predictive of TE events ( P = 0.014). Overall, the incidence of the TE events in patients with CHA2DS2VASc ≥ 2 was 0.6 per 100 patient-years whereas seven haemorrhagic events occurred, all of them in the ON-OAT patients (7/267 = 2.6%). Conclusion Patients with AF undergoing transcatheter ablation have a lower incidence of TE events as compared with the general AF population, regardless of OAT maintenance. The unpredictable risk of AF recurrence, mandate the routine use of the CHADS2, CHA2DS2VASc, and HAS-BLED scores to guide clinical decision regarding OAT management in this peculiar setting of patients. The potential protective role of rhythm control strategy in the TE events needs to be confirmed by future large randomized trials.

Atrial fibrillation increases thromboembolic risk. Oral anticoagulation with antivitamin K (AVK) reduces thromboembolic event rate, but increases hemorrhagic risk.The aim of the present study was to describe long-term cerebral thromboembolic/hemorrhagic event rates in atrial fibrillation patients managed by rhythm control, pursued by atrial fibrillation transcatheter ablation (AFTCA), and rate control strategy.One thousand and five hundred consecutive patients referring to three medical care centers for atrial fibrillation were retrospectively divided into three groups: AFTCA maintaining AVK (group A); AFTCA discontinuing AVK (group B); and rate control strategy and AVK (group C). Thromboembolic and hemorrhagic events were recorded in 60 ± 28 months of follow-up. Thromboembolic events did not differ between the groups (5/500, 1% group A; 7/500, 1.4% group B; 11/500, 2.2% group C; P = 0.45), and hemorrhagic events were greater in group A (9/500, 1.8%) and C (12/500, 2.4%) than in group B (no events; P = 0.003). Among patients with CHA2DS2 VASc score 2 or less, thromboembolic events did not differ in the group discontinuing AVK (group B, 4/388, 1%) or not (group A, 1/319, 0.3%; P = 0.38), whereas hemorrhagic events were more common in patients on AVK (5/319, 1.5% group A and 3/175, 1.7% group C; P = 0.02) compared with those discontinuing AVK (0/388, group B). Following AFTCA (groups A and B), 299/1000 experienced atrial fibrillation relapses; all thromboembolic events (12/299, 4%) occurred within these patients (P 0.001).Considering this multicenter design study, AVK continuation following AFTCA, especially within patients with low-to-intermediate thromboembolic risk, confers a hemorrhagic risk greater to the thromboembolic protective effect. All thromboembolic events following AFTCA occur within patients experiencing atrial fibrillation relapses; therefore, in patients with high thromboembolic risk routine rhythm monitoring is essential after AVK discontinuation.

Background: Current definition of persistent atrial fibrillation (PAF) enrolls a heterogeneous population with different atrial fibrillation (AF) exposure and degree of atrial substrate. Study aims were to evaluate acute and long-term results of electrical cardioversion (ECV) and to identify temporal cutoff of previous AF exposure to reclassify PAF in subgroups with different chance of sinus rhythm (SR) maintenance. Methods: Five hundred twenty-one patients (66% men; age 69 ± 10 years) with PAF undergoing ECV, were divided in four groups according to AF duration at the time of ECV: group A with AF ≤2 months (141 patients); group B with AF >2 and ≤4 months (176 patients); group C with AF >4 and ≤6 months (89 patients); and group D with AF >6 months and 6 months helps in selecting patients that can take greater advantage of the procedure. (PACE 2012; 35:1126–1134)

Background Symptomatic cerebral thromboembolism occurs in 0.4% of transcatheter atrial fibrillation ablation procedures. Silent cerebral events, instead, have recently been reported in up to 14%, especially clustered within patients undergoing cardioversion at the end of the procedure. The present study reports the incidence of silent cerebral thromboembolism, assessed by cerebral MRI, delaying electrical cardioversion, in case of lack of sinus rhythm restoration at the end of the procedure, after 4 weeks of effective anticoagulation. Methods and results Ninety-five consecutive patients with antiarrhythmic drug refractory atrial fibrillation were referred for transcatheter ablation and enrolled in the study. All patients underwent pre-ablation and post-ablation cerebral MRI. Overall, post-ablation cerebral MRI registered new thromboembolism in six (6%) patients. Fifty-five (58%) patients remained in sinus rhythm throughout the procedure and 40 (42%) reported persistent atrial fibrillation, yielding a silent thromboembolism incidence of 5 and 8%, respectively. In particular, silent thromboembolism was registered in one (4%) of the 25 patients achieving sinus rhythm by catheters, in two (18%) of the 11 patients spontaneously restoring sinus rhythm shortly following the procedure and in none of the four patients cardioverted following 4-week anticoagulation. In a matched reference population, a significantly higher percentage of patients (15, 16% vs. 6, 6%; P = 0.03) suffered from a new post-ablation thromboembolism; particularly within patients terminating the procedure in atrial fibrillation. Delaying cardioversion reduced silent cerebral thromboembolism from 38 to 13%. Conclusion Delaying electrical cardioversion after a 4-week anticoagulation period reduced the risk of silent cerebral thromboembolism and is a viable and safer option in patients terminating a transcatheter ablation procedure in atrial fibrillation.

The natural history of atrial fibrillation (AF) is characterized by gradual increase in duration and frequency of relapses until a definitive shift to permanent AF. Heart disease and comorbidities modulate AF progression. However, to date the influence of catheter ablation on AF evolution has rarely been investigated.The purpose of this study was to identify long-term predictors of AF progression in a large cohort of patients undergoing AF transcatheter ablation (AFTCA).A total of 889 patients (mean age 57 ± 11 years; 53.3% paroxysmal AF, 40.5% persistent AF, 6.2% long-standing AF) underwent AFTCA. All patients underwent pulmonary vein isolation, with linear lesions and complex fractionated atrial electrogram ablation reserved for patients with persistent/long-standing AF and/or confirmed structural heart disease.After median follow-up of 64 months (range 41-84 years), AF progression despite AFTCA occurred in 57 cases (6.4%). However, AF progression was much more pronounced in patients with persistent (10%) or long-standing persistent AF (14.6%) than in those with paroxysmal AF (2.7%, P.001). Furthermore, AF progression was more frequently reported in patients who presented with underlying comorbidities/cardiomyopathies (9.1%) than in those who presented with lone AF (29.9%, P.001). At multivariate analysis, comorbidities/cardiomyopathies and baseline persistent/long-standing AF proved to be independent predictors of progression (odds ratio 11.3, 95% confidence interval 2.6-48.0, P.001, and odds ratio 1.6, 95% confidence interval 1.2-2.1, P.001, respectively).The presence of comorbidities/cardiomyopathies and persistent/long-standing AF seem to predict AF progression in patients undergoing AFTCA. Performing AFTCA in the paroxysmal phase of the arrhythmia may reduce progression of AF to its permanent form.

We prospectively compared the efficacy, safety, and quality of life (QoL) impact of catheter ablation versus antiarrhythmic drugs (AAD) in elderly patients with persistent atrial fibrillation (AF).Four hundred and twelve consecutive patients, aged ≥ 70 years, underwent ablation (Group A, 153 patients) or AAD (Group B, 259 patients). Study endpoints: treatment failure (any AF/AT lasting30 seconds) and treatment-related adverse events (acute when ≤1 month of procedure and long term when1 month). At a follow-up of 60 ± 17 months, 43% and 46% patients in Group B versus 58% and 76% in Group A were in sinus rhythm (SR), respectively, after one (P = 0.003) and 2 procedures (P0.001). Fifteen acute adverse events occurred (6.7% in Group A vs 1% in Group B, P0.001), mainly periprocedural cerebral thromboembolism (3.3% in Group A vs 0.7% in Group B, P = 0.058). Previous TIA/stroke resulted the only independent predictor of periprocedural cerebrovascular accidents (OR 1.2, 95%IC 1.1-1.3). At follow-up, 74 long-term adverse events occurred (7.7% in Group A vs 23.9% in Group B, P0.001) with Group B patients more often experiencing AAD-related adverse events (12.7% vs 2.6%, P0.001). Group A and absence of AF/AT recurrences significantly improved QoL scores (P0.001).In elderly persistent AF patients, catheter ablation is more effective in maintaining SR and in improving QoL than AAD but is affected by a higher risk of embolic complications, particularly in patients with previous TIA/stroke. Over time, Group A patients more likely discontinued AAD with a reduction of long-term adverse events.

Silent cerebral lesions (SCL) are a sensitive tool to evaluate thromboembolic risk of catheter ablation. Recent data showed the possibility to reduce thrombus formation when the electrode-tissue interface cooling is optimized by a homogeneous flushing of saline along the entire surface of the distal electrode through a larger number of irrigation holes. The study aim is to compare procedural parameters and safety of pulmonary vein isolation (PVI) performed by using open-irrigated catheters with different irrigation design.Eighty patients (74% males; age 57 ± 12 years) with paroxysmal AF randomly underwent PVI performed with a new irrigation design catheter (group A, 40 patients) versus a standard irrigated catheter (group B, 40 patients). A cerebral magnetic resonance imaging (MRI) was performed before and after the procedure. Postprocedural brain MRI unveiled SCL in 2 patients in group A and in 3 in group B (5% vs 7.5%, P = 0.500). Intraprocedural ACT was the only independent factor associated with the occurrence of SCL (OR = 0.996; 95% CI 0.994-0.998, P0.001). Among procedural parameters, we observed a reduction of irrigation saline volume of 662 mL in group A versus group B (P0.001).PVI performed with a new irrigated catheter did not reduce significantly the SCL risk when compared to a standard irrigated catheter. Intraprocedural ACT reduces the SCL risk of 0.4% for each point of ACT increase. For ACT320 seconds no SCL occurred. Finally, compared to a standard irrigated catheter, PVI performed with a new irrigation design catheter reduces significantly saline volume infusion.

By the mid '90s, transcatheter ablation of atrial fibrillation (AF) has undergone a strong and impetuous advance, becoming a well known and worldwide accepted therapeutic procedure offered to patients with different types of AF and clinical features. The present paper aims to describe the main concepts behind the evolution of transcatheter ablation of AF, to review clinical indications, and to analyze current outcomes in terms of efficacy and safety.

AF Ablation Technologies and Silent Cerebral Ischemic Lesions. Introduction: Silent cerebral ischemic lesions have recently emerged as the most frequent complications after pulmonary vein isolation (PVI). To reduce thromboembolic complications, new types of catheters and energy source have been introduced in clinical practice. The study purpose is to compare the incidence of new silent cerebral ischemic events in patients with paroxysmal atrial fibrillation (PAF) undergoing PVI with different ablation technologies. Methods and Results: One hundred and eight patients (67% men; age 56 ± 9 years) with PAF were enrolled in a consecutive manner to undergo PVI performed with irrigated radiofrequency (RF) catheter (Group 1, 36 patients), multielectrode catheter (PVAC) associated with duty-cycled RF generator (Group 2, 36 patients) and cryoballoon (Group 3, 36 patients). The protocol included a cerebral magnetic resonance imaging before and after the procedure. After PVI, the following patients showed new silent cerebral ischemic lesions at postprocedural cerebral MRI: 3 patients in Group 1 (8.3%), 14 patients in Group 2 (38.9%), 2 patients in Group 3 (5.6%). PVAC related to higher incidence of silent cerebral ischemic events compared to irrigated RF (P = 0.002) and cryoballoon (P = 0.001), whereas no statistical differences were found between irrigated RF catheter and cryoballoon groups (8.3% vs 5.6%, P = 0.5). At the multivariate analysis, the only independent predictor of new ischemic asymptomatic cerebral lesions after PVI was ablation performed with PVAC (OR 1.48 95% CI 1.19–1.62, P < 0.001). Conclusion: The incidence of silent cerebral lesions after PVI is different depending on technologies used: PVAC increases the risk of 1.48 times compared to irrigated RF and cryoballoon ablation. (J Cardiovasc Electrophysiol, Vol. 22, pp. 961-968, September 2011)

Aims To compare in a randomized and prospective fashion the outcome of atrial fibrillation (AF) ablation either after one procedure or after two procedures using the Carto-XP vs. the Carto-Merge mapping system in two different AF populations. Methods and results Two hundred and ninety-nine patients with paroxysmal and persistent AF were enrolled in the study. One hundred and fifty patients with paroxysmal or persistent AF were randomly assigned to the Carto-Merge group and 149 patients to the Carto-XP group. The Carto-Merge patients underwent magnetic resonance imaging (MRI) of left atrium (LA) the day before the ablation. The ablation scheme included electrical disconnection of the pulmonary veins plus linear lesions. In the Carto-Merge patients, the three-dimensional MRI of the LA reconstruction merged with the electroanatomical map, and in the Carto-XP patients, the electroanatomical map guided the procedure. Considering the overall population with paroxysmal AF, 54% maintained sinus rhythm (SR), whereas in the persistent AF population, SR was present in 43% of the patients at the 12-month follow-up. In patients with paroxysmal AF, 52% in the Carto-XP group and 55% in the Carto-Merge group maintained SR without drugs. Procedure durations and exposure to X-ray in the Carto-XP group were 94.6 ± 17.5 and 40.4 ± 13.5 min, respectively. In the Carto-Merge group, duration and X-ray exposure were 89 ± 41.6 and 22.1 ± 11.4 min, respectively. Considering the patients with persistent AF at the12-month follow-up, 44% in the Carto-XP group and 42% in the Carto-Merge group maintained SR without drugs. Procedure durations and X-ray exposure in the Carto-XP group were 102.9 ± 22.9 and 58 ± 8.7 min, respectively. In the Carto-Merge group, both duration and X-ray exposure were 114.4 ± 50.9 and 28.8 ± 14.3 min, respectively. Conclusion Image integration using Carto-Merge in patients undergoing catheter ablation for paroxysmal and persistent AF does not significantly improve the clinical outcome, but shortens the X-ray exposure.

Background— Radiofrequency left atrial catheter ablation has become a routine procedure for treatment of atrial fibrillation. The aim of this study was to assess with preprocedural and postprocedural cerebral magnetic resonance imaging the thromboembolic risk, either silent or clinically manifest, in the context of atrial fibrillation ablation. The secondary end point was the identification of clinical or procedural parameters that correlate with cerebral embolism. Methods and Results— A total of 232 consecutive patients with paroxysmal or persistent atrial fibrillation who were candidates for radiofrequency left atrial catheter ablation were included in the study. Pulmonary vein isolation or pulmonary vein isolation plus linear lesions plus atrial defragmentation with the use of irrigated-tip ablation catheters was performed. All of the patients underwent preprocedural and postablation cerebral magnetic resonance imaging. A periprocedural symptomatic cerebrovascular accident occurred in 1 patient (0.4). Postprocedural cerebral magnetic resonance imaging was positive for new embolic lesions in 33 patients (14). No clinical parameters such as age, hypertension, diabetes mellitus, previous history of stroke, type of atrial fibrillation, and preablation antithrombotic treatment showed significant correlation with ischemic cerebral embolism. Procedural parameters such as activated clotting time value and, in particular, electric or pharmacological cardioversion to sinus rhythm correlated with an increased incidence of cerebral embolism. Cardioversion was also associated with an increased risk of 2.75 (95 confidence interval, 1.29 to 5.89; P =0.009). Conclusions— Radiofrequency left atrial catheter ablation carries a low risk of symptomatic cerebral ischemia but is associated with a substantial risk of silent cerebral ischemia detected on magnetic resonance imaging. Independent risk factors for cerebral thromboembolism are the level of activated clotting time and, in particular, the electric or pharmacological cardioversion to sinus rhythm during the procedure.

ObjectivesThe aim of this study was to compare the prevalence of silent cerebral ischemia (SCI) and cognitive performance in patients with paroxysmal and persistent atrial fibrillation (AF) and controls in sinus rhythm.BackgroundLarge registries have reported a similar risk for symptomatic stroke in both paroxysmal and persistent AF. The relationship among paroxysmal and persistent AF, SCI, and cognitive impairment has remained uncharted.MethodsTwo hundred seventy subjects were enrolled: 180 patients with AF (50% paroxysmal and 50% persistent) and 90 controls. All subjects underwent clinical assessment, neurological examination, cerebral magnetic resonance, and the Repeatable Battery for the Assessment of Neuropsychological Status.ResultsAt least 1 area of SCI was present in 80 patients (89%) with paroxysmal AF, 83 (92%) with persistent AF (paroxysmal vs. persistent, p = 0.59), and 41 (46%) controls (paroxysmal vs. controls and persistent vs. controls, p