title: Does periprocedural anticoagulation management of atrial fibrillation affect the prevalence of silent thromboembolic lesion detected by diffusion cerebral magnetic resonance imaging in patients undergoing radiofrequency atrial fibrillation ablation with open irrigated catheters? Results from a prospective multicenter study.
abstract: BACKGROUND
  Silent cerebral ischemia (SCI) has been reported in 14% of cases after catheter ablation of atrial fibrillation (AF) with radiofrequency (RF) energy and discontinuation of warfarin before AF ablation procedures.
  
  
  OBJECTIVE
  The purpose of this study was to determine whether periprocedural anticoagulation management affects the incidence of SCI after RF ablation using an open irrigated catheter.
  
  
  METHODS
  Consecutive patients undergoing RF ablation for AF without warfarin discontinuation and receiving heparin bolus before transseptal catheterization (group I, n = 146) were compared with a group of patients who had protocol deviation in terms of maintaining the therapeutic preprocedural international normalized ratio (patients with subtherapeutic INR) and/or failure to receive pretransseptal heparin bolus infusion and/or ≥2 consecutive ACT measurements <300 seconds (noncompliant population, group II, n = 134) and with a group of patients undergoing RF ablation with warfarin discontinuation bridged with low molecular weight heparin (group III, n = 148). All patients underwent preablation and postablation (within 48 hours) diffusion magnetic resonance imaging.
  
  
  RESULTS
  SCI was detected in 2% of patients (3/146) in group I, 7% (10/134) in group II, and 14% (21/148) in group III (P <.001). "Therapeutic INR" was strongly associated with a lower prevalence of postprocedural silent cerebral ischemia (SCI). Multivariable analysis demonstrated nonparoxysmal AF (odds ratio 3.8, 95% confidence interval 1.5-9.7, P = .005) and noncompliance to protocol (odds ratio 2.8, 95% confidence interval 1.5-5.1, P <.001] to be significant predictors of ischemic events.
  
  
  CONCLUSIONS
  Strict adherence to an anticoagulation protocol significantly reduces the prevalence of SCI after catheter ablation of AF with RF energy.
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Albert Einstein College of Medicine at Montefiore Hospital, New York, New York; Department of Biomedical Engineering, University of Texas, Austin, Texas; Department of Cardiology, University of Foggia, Foggia, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Di Biase
authors.affiliation: Department of Medical Sciences, University of Turin, Turin, Italy.
authors.forename: Fiorenzo
authors.initials: F
authors.lastname: Gaita
authors.affiliation: Department of Medical Sciences, University of Turin, Turin, Italy.
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Toso
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Department of Cardiology, University of Foggia, Foggia, Italy.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Santangeli
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Prasant
authors.initials: P
authors.lastname: Mohanty
authors.affiliation: Austin Radiological Association, Austin, Texas.
authors.forename: Neal
authors.initials: N
authors.lastname: Rutledge
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Xue
authors.initials: X
authors.lastname: Yan
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Sanghamitra
authors.initials: S
authors.lastname: Mohanty
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Chintan
authors.initials: C
authors.lastname: Trivedi
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Rong
authors.initials: R
authors.lastname: Bai
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Justin
authors.initials: J
authors.lastname: Price
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Rodney
authors.initials: R
authors.lastname: Horton
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: G Joseph
authors.initials: GJ
authors.lastname: Gallinghouse
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Salwa
authors.initials: S
authors.lastname: Beheiry
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Jason
authors.initials: J
authors.lastname: Zagrodzky
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Robert
authors.initials: R
authors.lastname: Canby
authors.affiliation: California Pacific Medical Center, San Francisco, California.
authors.forename: Jean François
authors.initials: JF
authors.lastname: Leclercq
authors.affiliation: Department of Rythmology, CMC Parly II Le Chesnay, Le Chesnay, France.
authors.forename: Franck
authors.initials: F
authors.lastname: Halimi
authors.affiliation: Division of Cardiology, Cardinal Guglielmo Massaia Hospital, Asti, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Scaglione
authors.affiliation: Division of Radiology, Cardinal Guglielmo Massaia Hospital, Asti, Italy.
authors.forename: Federico
authors.initials: F
authors.lastname: Cesarani
authors.affiliation: Radiology Institute, Department of Surgical Sciences, University of Turin, Turin, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Faletti
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: Javier
authors.initials: J
authors.lastname: Sanchez
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas; Department of Biomedical Engineering, University of Texas, Austin, Texas; California Pacific Medical Center, San Francisco, California; Division of Cardiology, Stanford University, Palo Alto, California; Heart and Vascular Center, Case Western Reserve University, Cleveland, Ohio. Electronic address: dr.natale@gmail.com.
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D002545:Brain Ischemia / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology; D017115:Catheter Ablation / Q000295:instrumentation*; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods*; D004867:Equipment Design; D005060:Europe / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D013923:Thromboembolism / Q000150:complications / Q000175:diagnosis / Q000517:prevention & control*; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014859:Warfarin / Q000008:administration & dosage*
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Ablation; Atrial fibrillation; Periprocedural; Radiofrequency; Silent cerebral ischemia; Stroke; Warfarin