title: Ischemic Stroke or Systemic Embolism After Transseptal Ablation of Arrhythmias in Patients With Cardiac Implantable Electronic Devices.
abstract: BACKGROUND
  Incidental mobile thrombi are commonly found on endovascular leads of cardiac implantable electronic devices (CIEDs). Transseptal puncture for catheter ablation of arrhythmia poses a risk for paradoxical embolism. We examined risk of ischemic stroke, transient ischemic attack (TIA), or systemic embolism after transseptal ablation in patients with and without CIEDs.
  
  
  RESULTS
  Using a national administrative claims database, 31 720 patients who underwent a transseptal catheter ablation between January 2004 and September 2014 were identified. Two propensity-matched cohorts were created by matching demographic variables, administrative variables, Charlson Comorbidity Index, CHA2DS2-Vasc score, and year and indication for ablation (5533 and 11 300 patients with and without CIEDs). Incidence rates and Cox proportional hazards models were used to estimate risk of ischemic stroke, TIA, or systemic embolism for patients with and without CIEDs. Impact of oral anticoagulation (OAC) use on the endpoint was examined. Over a mean follow-up of 2.1 years, the incidence of the combined endpoint was 1.9 per 100 person-years in patients with CIEDs and 1.5 per 100 person-years in patients without CIEDs (P=0.03). Among patients not on OAC, presence of a cardiac device was associated with an increased risk (hazard ratio [HR], 1.71 [1.24-2.35]; P<0.01), whereas there was no association noted among patients treated with OAC (HR, 0.98 [0.75-1.28]).
  
  
  CONCLUSIONS
  CIEDs are associated with an increased risk of stroke, TIA, or systemic embolism after transseptal ablation, but this risk is attenuated with postablation OAC use. Role of anticoagulation post-transseptal ablation in patients with CIED warrants further investigation.
authors.affiliation: Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN madhavan.malini@mayo.edu.
authors.forename: Malini
authors.initials: M
authors.lastname: Madhavan
authors.affiliation: Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN Division of Health Care Policy and Research, Department of Health Services Research, Mayo Clinic, Rochester, MN.
authors.forename: Xiaoxi
authors.initials: X
authors.lastname: Yao
authors.affiliation: Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN Optum Labs, Cambridge, MA.
authors.forename: Lindsey R
authors.initials: LR
authors.lastname: Sangaralingham
authors.affiliation: Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Asirvatham
authors.affiliation: Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Friedman
authors.affiliation: Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: McLeod
authors.affiliation: Department of Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Alan M
authors.initials: AM
authors.lastname: Sugrue
authors.affiliation: Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Christopher V
authors.initials: CV
authors.lastname: DeSimone
authors.affiliation: Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Noseworthy
mesh_terms: D000368:Aged; D001145:Arrhythmias, Cardiac / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects*; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D005260:Female; D006346:Heart Septum / Q000601:surgery*; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000209:etiology*; D013923:Thromboembolism / Q000209:etiology*
keywords: atrial fibrillation; cardiac ablation; stroke; systemic embolism; transseptal puncture