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LV catheter ablation for certain arrhythmias may confer risk for brain lesions
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In a small study, patients who underwent left ventricular catheter ablation for premature ventricular complexes were more likely to have subclinical brain emboli after the procedure than those who underwent right ventricular catheter ablation.
“Our study finding is relevant to a large number of patients undergoing this procedure and hopefully will inspire many studies to understand the meaning of and how to mitigate these lesions,” Gregory M. Marcus, MD, MAS, director of clinical research in the division of cardiology at the University of California, San Francisco, said in a press release. “This also will become an important consideration as we think about how to optimally help the large number of people out there with [premature ventricular complexes].”
Marcus and colleagues analyzed 18 consecutive patients (mean age, 58 years; 50% men) scheduled to undergo catheter ablation for ventricular tachycardia or premature ventricular complexes, comparing those who underwent LV ablation (n = 12; 10 with premature ventricular complexes) with those who underwent RV ablation (n = 6; five with premature ventricular complexes).
All ablation procedures were performed with radiofrequency energy and all patients underwent brain MRI before the procedure and within 1 week after.
The primary outcome was presence of embolic infarcts, defined as new foci of reduced diffusion and high signal intensity on MRI within a vascular distribution.
Marcus and colleagues identified embolic infarcts in 58% of those in the LV ablation group (16 emboli in seven patients) compared with 0% of those in the RV ablation group (P = .04).
Of the 11 patients who underwent a retrograde approach to the LV, seven had at least one new embolic infarct, the researchers wrote. – by Erik Swain
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Jagmeet P. Singh, MD, DPhil, FACC, FHRS
The article by Marcus and colleagues highlights a very critical issue pertinent to LV endocardial ablation therapy. The occurrence of cerebral emboli in greater than half of the patients is extremely concerning, especially since these procedures were performed under ideal conditions, ie, on appropriate blood thinners and with current ablation technology. This study emphasizes the need for us to begin to more carefully weigh the risk-benefit ratio of the ablation and at the same time also explain this potential downside to our patients undergoing a left-sided ventricular ablation. Even though patients with documented cerebral emboli may have no immediate clinical manifestations of a stroke, there are some data to suggest that this may have an adverse neurocognitive impact over time. This study highlights the need for us to better risk-stratify patients for an ablation, develop emboli protection methods and investigate if a transseptal approach may mitigate some of this risk.
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