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Observational Study
. 2024 Aug 30;26(9):euae222.
doi: 10.1093/europace/euae222.

Microembolizations in the arterial cerebral circulation during atrial fibrillation ablation: cryoballoon technique advantages and neurocognitive safety-results of a prospective observational study

Damir Erkapic  1   2 , Konstantinos Roussopoulos  1 , Marko Aleksic  1 , Kay Felix Weipert  1 , Korkut Sözener  1   3 , Karel Kostev  4 , Jens Allendörfer  5 , Josef Rosenbauer  1 , Samuel Sossalla  2 , Dursun Gündüz  1   2 , Christian Tanislav  6
Affiliations
Observational Study

Microembolizations in the arterial cerebral circulation during atrial fibrillation ablation: cryoballoon technique advantages and neurocognitive safety-results of a prospective observational study

Damir Erkapic et al. Europace. .

Abstract

Aims: The significance of micro-embolic signals (MESs) during atrial fibrillation (AF) ablation is unclear. Previous studies had limitations, and cryoballoon (CB) ablation patients were under-represented. Minimizing MESs is recommended due to their uncertain neurocognitive impact.

Methods and results: This prospective observational study included AF patients from a German centre between February 2021 and August 2022. Patients were equally divided into paroxysmal (Group A) and persistent (Group B) AF. Group A received cryoballoon-pulmonary vein isolation only, while Group B also had left atrial roof ablation. MESs were detected using transcranial Doppler ultrasonography during ablation. Neurocognitive status was assessed pre- and post-procedure and at 3 months using the CERAD Plus battery. The study analyzed 100 patients with a median age of 65.5 years. A total of 19 698 MESs were observed, with 80% being gaseous and 20% solid in origin, primarily occurring during pulmonary vein angiography and the balloon freeze and thawing phase. The median MES per patient was 130 (IQR: 92-256) in total, 298 (IQR: 177-413) in bilateral (36%), and 110 (IQR: 71-130) in unilateral (64%) recordings. No significant difference in total MES counts was found between the groups. None of the 11 neuropsychological tests showed cognitive decline post-procedure or at 3 months.

Conclusion: Our observations confirm that neurocognitive abilities are not affected either 24 h or 3 months after AF ablation using the CB technique. However, despite the low MES burden associated with the CB, more work is needed to reduce small embolic events during AF ablation.

Keywords: Cryoballoon; LARA; MES; Microembolization; Neurocognitive safety; PVI.

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Conflict of interest statement

Conflict of interest: none declared.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Microembolic signal detection using Transcranial Doppler Ultrasonography. (A) Transcranial Doppler ultrasonography displaying the flow signal over the arteria cerebri media; (B) normal flow profile over the middle cerebral artery; (C) high-intensity signal (HITS) with strictly unidirectional signal within the Doppler spectrum implying a ‘solid’ embolus; (D) large, high-intensity bidirectional signal (HITS) exceeding the Doppler spectrum implying a ‘gaseous’ embolus; (E) many (innumerable) HITS, indicating a shower. Adapted and modified from Erkapic et al. HITS, high-intensity signal.
Figure 2
Figure 2
Timeline step-by-step demasking of number and type of microembolic signals during cryoballoon pulmonary vein isolation. HITS, high-intensity signal; LA, left atrium; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; PV, pulmonary vein; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein.
See this image and copyright information in PMC

References

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