title: 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).
authors.affiliation: Heart Center Bad Neustadt, Bad Neustadt, Germany.|Ruhr-University Bochum, Bochum, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Deneke
authors.affiliation: University Hospital Bordeaux, Bordeaux, FRA.
authors.forename: Pierre
authors.initials: P
authors.lastname: Jais
authors.affiliation: Cardiology Division, Cardinal Guglielmo Massaia Hospital, Asti, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Scaglione
authors.affiliation: Department of Radiology, Heart Center Bad Neustadt, Bad Neustadt, Germany.
authors.forename: Rainer
authors.initials: R
authors.lastname: Schmitt
authors.affiliation: Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA.|Department of Biomedical Engineering, University of Texas, Austin, Texas, USA.|Albert Einstein College of Medicine at Montefiore Hospital New York, New York, USA.|Department of Cardiology, University of Foggia, Foggia, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: DI Biase
authors.affiliation: Department of Radiology, Heart Center Bad Neustadt, Bad Neustadt, Germany.
authors.forename: Georgios
authors.initials: G
authors.lastname: Christopoulos
authors.affiliation: Heart Center Bad Neustadt, Bad Neustadt, Germany.
authors.forename: Anja
authors.initials: A
authors.lastname: Schade
authors.affiliation: Ruhr-University Bochum, Bochum, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Mügge
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Hospital Cologne-Porz, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Bansmann
authors.affiliation: Heart Center Bad Neustadt, Bad Neustadt, Germany.
authors.forename: Karin
authors.initials: K
authors.lastname: Nentwich
authors.affiliation: Heart Center Bad Neustadt, Bad Neustadt, Germany.|Ruhr-University Bochum, Bochum, Germany.
authors.forename: Patrick
authors.initials: P
authors.lastname: Müller
authors.affiliation: Heart Center Bad Neustadt, Bad Neustadt, Germany.
authors.forename: Joachim
authors.initials: J
authors.lastname: Krug
authors.affiliation: Heart Center Bad Neustadt, Bad Neustadt, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Roos
authors.affiliation: Heart Center Bad Neustadt, Bad Neustadt, Germany.
authors.forename: Phillip
authors.initials: P
authors.lastname: Halbfass
authors.affiliation: Ruhr-University Bochum, Bochum, Germany.|Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
authors.affiliation: Division of Cardiology, Department of Medical Sciences, University of Turin, Italy.
authors.forename: Fiorenzo
authors.initials: F
authors.lastname: Gaita
authors.affiliation: Department of Cardiovascular Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA.
authors.forename: David
authors.initials: D
authors.lastname: Haines
mesh_terms: D058070:Asymptomatic Diseases; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D002545:Brain Ischemia / Q000175:diagnosis / Q000209:etiology*; D017115:Catheter Ablation / Q000009:adverse effects*; D032921:Consensus; D038524:Diffusion Magnetic Resonance Imaging; D006801:Humans; D020766:Intracranial Embolism / Q000175:diagnosis / Q000209:etiology*; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: atrial fibrillation; catheter ablation; cryoablation; silent cerebral infarction; stroke