Silent Cerebral Infarcts Following Left-Sided Accessory Pathway Ablation in Wolff-Parkinson-White (WPW) Syndrome: A Preliminary Report

Impact of Silent Cerebral Embolism during and after Left Atrial Appendage Occlusion on Long-Term Cognitive Function

BACKGROUND

Left atrial appendage occlusion (LAAO) was associated with a high incidence of procedure-related silent cerebral embolism (SCE). There are limited data regarding the long-term cognitive trajectory of patients undergoing LAAO. The aim of our study was to comprehensively assess the acute and long-term impact of SCE during and after LAAO.

METHODS

Consecutive patients with atrial fibrillation referred for LAAO from the First Affiliated Hospital with Nanjing Medical University between February 2021 and February 2023 were included. All patients underwent magnetic resonance imaging and cognitive assessments before and within 48 hours after the procedure. These evaluations were also repeated at 45-day, 3-month, 6-month, and 1-year follow up.

RESULTS

Out of 75 patients included in the final analysis, 29 (38.7%) patients suffered from new SCE during LAAO. Patients with SCE exhibited a significant decline in cognitive function (Mini-Mental State Examination) immediately after the procedure (P<0.001), which was not reversible during 1-year follow-up (P<0.001). Additionally, with time going on, the gap in cognitive function between patients with and without SCE became wider (SCE × 1 year: B=-4.81 [95% CI, -5.58 to -4.05]; P<0.001). New-onset SCE was detected in 11 (14.7%) patients during the follow-up magnetic resonance imaging, which also showed a decline in cognitive function (P=0.004). The results in Montreal Cognitive Assessment scores were consistent with Mini-Mental State Examination.

CONCLUSIONS

LAAO-related SCE is associated with a marked impairment in cognitive function immediately after the procedure and is irreversible over a 1-year follow-up. New magnetic resonance-detected SCE during follow-up after LAAO would also be associated with a decline in cognitive function.

Silent cerebral ischemic lesions in ablation-naïve patients with non-valvular atrial fibrillation: Does the pulmonary vein anatomy matter?

BACKGROUND

Silent cerebral ischemic lesions (SCILs) detected by magnetic resonance imaging (MRI) can precede symptomatic stroke, the risk of which is increased five-fold in atrial fibrillation (AF) patients. In our study, we aimed to evaluate the initial incidence of SCILs in the population of patients referred for ablation due to symptomatic AF and to identify possible risk factors.

METHODS

A total of 110 patients, with a mean age (SD) of 59.9 (9.4) years, referred for ablation, were included in the study. In all patients, MRI was performed before the procedure to evaluate the incidence of SCILs in the ablation-naïve patients.

RESULTS

MRI revealed preexisting SCIL in 81/110 patients (73.6%). Notably, SCILs were found in all patients with CHA₂DS₂-VASc score ≥ 4. In univariable analysis, age (p < 0.001), CHA₂DS₂-VASc score (p = 0.001), hypertension (p = 0.01), and anticoagulation duration (p = 0.023) were identified as significant risk factors for SCILs, while the presence of anatomical variants of left-sided common pulmonary veins trunk (LCPV) had negative prognostic value (p = 0.026). Multivariable logistic regression analysis identified age (p < 0.001) as the risk factor of preexisting SCILs, whereas the presence of LCPV trunk was associated with significantly lower (p = 0.005) SCILs incidence.

CONCLUSIONS

Silent cerebral ischemic lesions detected in MRI are frequent in the population of patients with non-valvular AF. The incidence of SCILs is higher in patients with long history of arrhythmia and higher CHA₂DS₂-VASc score. The relationship between the anatomy of pulmonary veins and the incidence of SCILs needs further investigation.

Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review

Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.

Antiplatelet and Anti-Coagulation Therapy for Left-Sided Catheter Ablations: What Is beyond Atrial Fibrillation?

Aim: International guidelines on the use of anti-thrombotic therapies in left-sided ablations other than atrial fibrillation (AF) are lacking. The data regarding antiplatelet or anticoagulation strategies after catheter ablation (CA) procedures mainly derive from AF, whereas for the other arrhythmic substrates, the anti-thrombotic approach remains unclear. This survey aims to explore the current practices regarding antithrombotic management before, during, and after left-sided endocardial ablation, not including atrial fibrillation (AF), in patients without other indications for anti-thrombotic therapy. Material and Methods: Electrophysiologists were asked to answer a questionnaire containing questions on antiplatelet (APT) and anticoagulation therapy for the following left-sided procedures: accessory pathway (AP), atrial (AT), and ventricular tachycardia (VT) with and without structural heart disease (SHD). Results: We obtained 41 answers from 41 centers in 15 countries. For AP, before ablation, only four respondents (9.7%) used antiplatelets and two (4.9%) used anticoagulants. At discharge, APT therapy was prescribed by 22 respondents (53.7%), and oral anticoagulant therapy (OAC) only by one (2.4%). In patients with atrial tachycardia (AT), before ablation, APT prophylaxis was prescribed by only four respondents (9.7%) and OAC by eleven (26.8%). At discharge, APT was recommended by 12 respondents (29.3%) and OAC by 24 (58.5%). For VT without SHD, before CA, only six respondents (14.6%) suggested APT and three (7.3%) suggested OAC prophylaxis. At discharge, APT was recommended by fifteen respondents (36.6%) and OAC by five (12.2%). Regarding VT in SHD, before the procedure, eight respondents (19.5%) prescribed APT and five (12.2%) prescribed OAC prophylaxis. At discharge, the administration of anti-thrombotic therapy depended on the LV ejection fraction for eleven respondents (26.8%), on the procedure time for ten (24.4%), and on the radiofrequency time for four (9.8%), with a cut-off value from 1 to 30 min. Conclusions: Our survey indicates that the management of anti-thrombotic therapy surrounding left-sided endocardial ablation of patients without other indications for anti-thrombotic therapy is highly variable. Further studies are necessary to evaluate the safest approach to these procedures.

Effect of nursing based on the hopeless self-esteem theory plus multi-dimensional intensive nursing for elderly patients with acute cerebral infarction complicated with depression

PURPOSE

To explore the effect of nursing based on the hopeless self-esteem theory plus multi-dimensional intensive nursing on the self-esteem level and prognosis of elderly patients with acute cerebral infarction (ACI) complicated with depression.

METHODS

Eighty patients with ACI complicated with depression who were treated in our hospital from September 2018 to September 2020 were selected and randomized into the observation group and the control group (n = 40 each). The observation group received the model of hopeless self-esteem theory combined with multi-dimensional intensive nursing, while the control group received conventional nursing. The clinical efficacy, depression degree, self-esteem level, living ability, quality of life, and attribution mode were compared.

RESULTS

The overall effective rate was reported at a notably higher rate in the observation group (90.00%) compared to the control group (65.00%) (P < 0.05); After intervention, the observation group had a markedly lower Geriatric Depression Scale (GDS) score than the control group (P < 0.05); After intervention, the observation group showed appreciably higher Rosenberg Self Esteem Scale (RSES) score and Barthel index compared to the control group (P < 0.05); After intervention, the observation group had a remarkably higher level of the quality of life in all dimensions than the control group (P < 0.05); After intervention, there were more positive events in the observation group as compared to the control group (P < 0.05), whereas there were more negative events in the control group as compared to the observation group (P < 0.05).

CONCLUSION

The hopeless self-esteem theory combined with multi-dimensional intensive nursing can apparently increase the self-esteem level of patients, establish a positive attribution mode, beef up their self-confidence, reduce the degree of depression, upgrade their postoperative living ability and quality of life, and improve prognosis and clinical efficacy.

Catheter ablation via the left atrium for atrioventricular nodal reentrant tachycardia: A narrative review

Background

Since 1996, it has been recognized that catheter ablation for atrioventricular nodal reentrant tachycardia (AVNRT) may require an approach through the left atrium.

Objective

The purposes are to present a case report and to provide a comprehensive narrative review on this topic.

Methods

A literature review of all articles that provided detailed information on patients who underwent catheter ablation via the left atrium for AVNRT was performed. The primary search queried PubMed using Medical Subject Headings (MeSH) terms "atrioventricular nodal reentrant tachycardia" and "left." The secondary search was performed by manual review of reference lists and Google Scholar citations of manuscripts retrieved by the primary search. The review was limited to the English language.

Results

The searches yielded 30 articles that described 79 patients. A case report was added. Therefore, the final review consisted of 80 patients. The prevalence of left atrial ablation for patients with AVNRT undergoing catheter ablation at tertiary care centers was approximately 1%. Failed right atrial ablation, with or without coronary sinus ablation, was the most common indication for left atrial ablation. Pooled data from 3 cohort studies estimated the acute success rate for radiofrequency ablation of the slow pathway at the septal or inferoparaseptal segments of the mitral valve annulus after failed right-sided ablation to be 90%. There were no reports of atrioventricular block requiring permanent pacemaker implantation.

Conclusion

Catheter ablation of the slow pathway via the left atrium is an important technique for AVNRT cases that are refractory to conventional ablation.

Silent cerebral infarcts following pulmonary vein isolation with different atrial fibrillation ablation techniques - incidence and risk factors

Introduction

Silent cerebral infarcts (SCIs) detected by diffusion-weighted magnetic resonance (DW-MRI) following atrial fibrillation (AF) ablation have been reported, with the incidence of 1-38%. We aimed to compare the incidence of SCIs following AF ablation with four different technologies and analyze the risk factors.

Material and methods

A total of 104 patients (mean age: 59.9 ±9.5 years, 68 males) with symptomatic AF, referred for ablation, were included in the study. The AF ablation was performed with irrigated radiofrequency point-by-point technique (RF group) in 24 patients, and with 3 different single-shot techniques: phased-RF (PVAC) in 46, second-generation cryoballoon (CB) in 24 and irrigated multipolar RF catheter (nMARQ) in 10 patients. In all patients DW-MRI was performed pre- and post-procedurally to evaluate the incidence of SCIs. Procedural parameters, complication rate and post-procedural SCI incidence were compared between the groups.

Results

Procedure (167.1 vs. 110.5 vs. 106.0 vs. 141.5 min, p < 0.001), fluoroscopy (22.7 vs. 15.9 vs. 16.3 vs. 15.3 min, p = 0.048) and LA dwell (101.5 vs. 53.9 vs. 56.0 vs. 97.0 min, p < 0.001) times compared respectively between RF, PVAC, CB and nMARQ groups were significantly shorter with single-shot techniques. The number of new-onset SCIs was 4/24 (16.7%) in RF, 7/46 (15.2%) in PVAC, 1/24 (4.2%) in CB and 1/10 (10%) in the nMARQ group. Univariate analysis identified procedure duration (p = 0.02), lower LV ejection fraction (p = 0.03), persistent form of arrhythmia (p = 0.007) and intraprocedural cardioversion (p = 0.002) as risk factors of new-onset SCIs.

Conclusions

Silent cerebral infarcts can be detected following AF ablation regardless of the technology used. Prolonged procedure time, lower ejection fraction, persistent form of arrhythmia and intraprocedural cardioversion increase the risk of SCIs.