Silent cerebral lesions following catheter ablation for atrial fibrillation: a state-of-the-art review

Abstract

Atrial fibrillation is associated with neurocognitive comorbidities such as stroke and dementia. Evidence suggests that rhythm control-especially if implemented early-may reduce the risk of cognitive decline. Catheter ablation is highly efficacious for restoring sinus rhythm in the setting of atrial fibrillation; however, ablation within the left atrium has been shown to result in MRI-detected silent cerebral lesions. In this state-of-the-art review article, we discuss the balance of risk between left atrial ablation and rhythm control. We highlight suggestions to lower the risk, as well as the evidence behind newer forms of ablation such as very high power short duration radiofrequency ablation and pulsed field ablation.

Keywords: Ablation; Atrial fibrillation; Cognition; Dementia; Neurocognitive; Neurological.

Graphical abstract

Figure 1

(A) Diffusion-weighted brain magnetic resonance imaging (DW-MRI) prior to pulmonary vein isolation (PVI); (B) DW-MRI post-PVI; and (C) echo-planar T2-weighted MRI at 3 months. Note the presence of a new embolic lesion following PVI which persists at 3 months in this case. Reproduced with permission from Martinek et al.

Figure 2

Approaches to minimize ablation-related silent cerebral lesion formation; AF, atrial fibrillation; DOAC, direct oral anticoagulant; ERACE, evaluation and reduction of asymptomatic cerebral embolism in ablation of atrial fibrillation (Verma et al. Circulation Arrhythmia & Electrophysiology 2013 Oct; 6(5):835–42); VKA, vitamin K antagonist.