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Catheter ablation for atrial fibrillation (AF) is associated with slightly better maintenance of sinus rhythm compared to conventional anti-arrhythmic therapy (AAD). However, current guidelines suggest use of catheter ablation only as a second line therapy for AF ablation. Invasiveness confers many risks to the procedure including the risk of periprocedural stroke and these risks often mitigate the advantage. The clinical significance of periprocedural stroke has been uncertain. However, a recent study suggests that not only the periprocedural strokes may be rare they are also unlikely to have any clinically significant long-term impact.
Dr.Patel and colleagues studied more than three thousand patients who underwent the pulmonary vein antrum isolation (PVAI), the most common catheter ablation technique used for AF ablation. The results were reported recently in journal of cardiovascular electrophysiology. The investigators found that the rate of periprocedural cerebrovascular thromboembolic events, defined as a new neurological weakness within 48 hours of procedure, was about 0.8%.
It is uncertain if these results can be extrapolated to all AF ablation at all centers in the country. Incidence of periprocedural stroke varies at different centers and is often dependent on operator experience, available treatment modalities, anticoagulation protocols used and the ablation strategy used. Prior similar studies have reported the incidence of periprocedural stroke between 0.28 to 5%.
Presence of persistent or permanent AF was found to predispose to risk of periprocedural stroke on multivariate analysis. It was unclear from the study if CHADS2 score could predict the likelihood of a periprocedural stroke. Only 15 out of 26 patients who had a stroke had a CHADS2 score of one or less.
The investigator were able to follow-up these patients for a minimum of 12 months and a mean of 38.4 months. The functional status of the patients with stroke was assessed by NIH stroke scale (NIHSS) at the onset of stroke and, modified Barthel’s index or modified Rankin’s scale on follow-up. Only two of the 26 patients with periprocedural stroke died during follow up.
The investigators report that most patients had only mild to moderate deficits at the onset of strokes, with only 3 of the 22 patients on whom NIHSS assessment was available having severe deficits. Two patients had a TIA by definition. Furthermore, there was no increased risk of recurrent strokes in these patients.
Functional recovery was reported to be excellent. Most surviving patients had complete recovery on the Barthel’s Index and very mild to no disability on the modified Rankin Score. All surviving patients were able to get back to activities of daily living during follow-up period.
As the investigators mention, the prognosis of in-hospital strokes is often better than that out of hospital stroke because of timely institution of therapy. Five patients with stroke in this study underwent angiography followed by mechanical thrombolysis and two of these received tPA. Other patients were managed with re-institution of anticoagulation with warfarin or heparin/LMWH.
The findings from the study are enlightening. Peri-procedural stroke may not as dreaded after all. When explaining the risk of periprocedural stoke to the candidates for the procedure of AF ablation, physicians also need to inform them about the likely insult that could result from it. The results from this study would go far in helping physicians answer this question more appropriately.
Patel D, Bailey SM, Furlan AJ, Ching M, Zachaib J, Di Biase L, Mohanty P,Horton RP, Burkhardt JD, Sanchez JE, Zagrodzky JD, Gallinghouse GJ, Schweikert R, Saliba W, Natale A. Long-term functional and neurocognitive recovery in patients who had an acute cerebrovascular event secondary to catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2010 Apr;21(4):412-7.
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