Silent cerebral events/lesions related to atrial fibrillation ablation: a clinical review
Abstract
Brain magnetic resonance imaging (MRI) has identified a high incidence of cerebral ischemia in asymptomatic patients after atrial fibrillation (AF) ablation (silent). Detection of cerebral ischemic events on MRI is based on acute hyperintense lesions on diffusion-weighted imaging. In the literature, the incidence is related to specifications of MRI and depends on the definition applied. In comparative studies, silent cerebral events (SCE, diffusion-weighted MRI [DWI] positive only) appear to be approximately 3 times more common compared to using a definition of silent cerebral lesions (SCL; without fluid attenuated inverse recovery sequence [FLAIR] positivity). Whereas the FLAIR sequence may turn positive within days after the ischemic event, SCE definition is highly sensitive for early phases of ischemic brain damage. SCE/SCL appear to represent cerebral ischemic infarcts and determine the "embolic fingerprint" of a specific ablation technology and strategy used. The optimum time point for detecting SCE is early after AF ablation (24-72 hours), whereas detection of SCL can only be performed within the first 2-7 days (due to delay of FLAIR positivity). Different technology-, procedure-, and patient-related parameters have been identified to play a role in the multifactorial genesis of SCE/SCL. In recent years, evidence has been gathered that there may be differences of SCE/SCL rates depending upon the ablation technology used, but small patient numbers and a large number of potential confounders hamper all studies. As major findings of recent studies, mode of periprocedural and intraprocedural anticoagulation has been identified as a major predictor for incidences of SCE/SCL. Whereas procedural characteristics related to higher SCE/SCL-rates may be modified, unchangeable patient-related factors should be taken into account for future individualized risk assessment. Novel ablation devices introduced into the market should be tested for their potential embolic fingerprint and refinements of ablation procedures to reduce their embolic potential should be prompted. The knowledge of "best practice" in terms of low SCE/SCL rates has prompted changes in work-flow, which have been implemented into ablation procedures using novel ablation devices. So far, no study has linked SCE/SCL to neuropsychological decline and the low number of AF-ablation-associated events needs to be weighted against the multitude of preexisting asymptomatic MRI-detected brain lesions related to the course of AF itself. Future studies are needed to evaluate if more white matter hyperintensities due to AF may be prevented by AF ablation (producing only a small number of SCE/SCL).
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Five to seven per cent of patients will suffer severe complications after catheter ablation of atrial fibrillation, and 2-3% will experience life-threatening but usually manageable complications.
“Five to seven per cent of patients will suffer severe complications after catheter ablation of AF, and 2-3% will experience life-threatening but usually manageable complications.727,[748][749][750]”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [749]
The clinical relevance of silent strokes after catheter ablation is unclear.
“The clinical relevance of this observation is unclear.749”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [749]
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2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H.-C., Heidbuchel, H., Hendriks, J., et al. (2016) · European Heart Journal · doi:10.1093/eurheartj/ehw210 · Cited by 6,418 · see citing works
2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H.-C., Heidbuchel, H., Hendriks, J., et al. (2016) · European Journal of Cardio-Thoracic Surgery · doi:10.1093/ejcts/ezw313 · Cited by 1,403 · see citing works
- Authors
- DENEKE, T., JAIS, P., SCAGLIONE, M., SCHMITT, R., DI BIASE, L., CHRISTOPOULOS, G., SCHADE, A., MÜGGE, A., BANSMANN, M., NENTWICH, K., MÜLLER, P., KRUG, J., ROOS, M., HALBFASS, P., NATALE, A., GAITA, F., & HAINES, D.
- Affiliations
- Ruhr University Bochum (DE)
- University Hospital Bordeaux Bordeaux FRA
- Azienda Sanitaria Locale di Asti (IT)
- Rhön-Klinikum (DE)
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center Austin Texas USA
- Heart Center Bad Neustadt Bad Neustadt Germany
- Institute for Diagnostic and Interventional Radiology Hospital Cologne‐Porz Germany
- St David's Medical Center (US)
- Division of Cardiology Department of Medical Sciences University of Turin Italy
- Oakland University (US)
- Corresponding author
- DENEKE, THOMAS
- ORCID
- Venue
- Journal of Cardiovascular Electrophysiology
- Publisher
- Wiley
- Published
- 2015-02-11
- Volume
- 26
- Issue
- 4
- Pages
- 455-463
- ISSN
- 1045-3873 (ISSN-L)
- 1540-8167
- OpenAlex
- W1950554745
- Cited by
- 170
- References
- 42
- Citations by year
- 2026: 7 · 2025: 8 · 2024: 21 · 2023: 15 · 2022: 10 · 2021: 13 · 2020: 18 · 2019: 16 · 2018: 20 · 2017: 23 · 2016: 15 · 2015: 4
- FWCI
- 3.55
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Cardiovascular Electrophysiology (publishedVersion)
- PubMed (publishedVersion)
- Institutional Research Information System University of Turin (University of Turin) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Advanced MRI Techniques and Applications
- Keywords
- atrial fibrillation ablation, cerebral embolism, diffusion-weighted imaging, FLAIR, anticoagulation, white matter hyperintensities, stroke risk, ablation devices, risk assessment, neuropsychological decline, asymptomatic brain lesions, atrial fibrillation
- MeSH terms
- Atrial Fibrillation, Brain Ischemia, Humans, Predictive Value of Tests, Risk Factors, Time Factors, Treatment Outcome, Catheter Ablation, Risk Assessment, Intracranial Embolism, Consensus, Diffusion Magnetic Resonance Imaging, Asymptomatic Diseases
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