Cardiac Rhythm Management
Articles Articles 2014 April

Letter from the Editor in Chief

DOI: 10.19102/icrm.2014.050401

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Dear Readers,

Are silent strokes following atrial fibrillation ablations preventable? While we all know that AF significantly increases the long-term risk of dementia, if we can prevent these asymptomatic strokes from our AF ablation procedures, can we improve long-term cognitive function by eliminating AF?

While I was giving a talk on this subject in Hong Kong at the Asian Pacific Heart Rhythm Society meeting last fall, I mentioned that we have not seen any of these asymptomatic strokes following AF ablation. We have done many head MRIs and have yet to diagnose a single case.

As part of this talk, which I have given many times, I suggested that the reason why we had not seen any silent strokes was likely due to one or more of the following reasons:

Our procedures or left atrial times are much shorter than those reported.
Once we have performed the transseptal catheterization, we leave no sheaths in left atrium during the procedure.
We perform AF ablations without stopping warfarin (therapeutic INR on the day of the procedure)
We always give full dose intravenous heparin prior to transseptal catheterization.
We only use the irrigated tip ablation catheter

When I have shared this finding at many meetings I'm sure many people in the audience just nodded and were thinking "yeah right, you are just not looking hard enough". This is probably because this was felt to be an inevitable complication of AF ablations as the reported occurrence of this is 7-38% in the 2012 HRS AF Ablation Consensus Statement.

While I believed that one or more of these interventions helped us to prevent this complication, deep down I wondered if this was really the case when everyone else was saying otherwise. I often thought to myself, could the reason why we don't see this complication be that we are just not doing the cranial MRI studies properly?

However, in Hong Kong this past fall it was different. Dr. Luigi Di Biase from the Texas Cardiac Arrhythmia Institute at St. David's Medical Center in Austin, Texas came up to me after the talk and shared with me that this was indeed possible. He then went on to say that they had some unpublished data showing that if the patient had a therapeutic INR and heparin was given prior to transseptal catheterization then you just do not see any silent strokes following AF ablation.

Today, as I was considering what I would share with you in this issue of the Journal, I came across this article in press at the Heart Rhythm Journal.1 My good friend, Luigi, was the lead author of this study.

In this study, they had a total of 428 patients. They found that if the patient had a therapeutic INR on the day of the procedure and full-dose heparin was given prior to going transseptal (ACT > 300), then the risk of a silent stroke following the ablation procedure was only 2%. While these asymptomatic strokes have not yet been associated with long-term cognitive dysfunction, I could only imagine that these brain lesions following AF ablation must have some detrimental effect. Interestingly, they too only used irrigated tip ablation catheters in this study.

I strongly urge you to read this article entitled "Does the peri-procedural Anticoagulation Management for AF Affect the Prevalence of Silent Thromboembolic Lesion detected by Diffusion Cerebral Magnetic Resonance Imaging (dMRI) in patients undergoing radiofrequency AF ablation with open Irrigated catheters? Results from a prospective multicenter study" by Dr. Dr. Luigi Di Biase and colleagues.1

The take home message from this study is that something so simple as continuing the warfarin with a therapeutic INR, using an irrigated tip ablation catheter, and giving a large dose of heparin before going transseptal could virtually eliminate this complication! With all of the advances in intracardiac echo, in this current age there just is no reason not to do the transseptal with the patient fully anticoagulated. As I have shared previously in a letter, we still have never seen a case of a pericardial effusion at our center from the transseptal procedure in more than 10,000 cases.

For those of you who like to use the balloon based ablation technologies, it is possible that the same results could be obtained. However, as this has not yet been studied it is still speculative at this time.

As always, I hope that this Journal continues to be a powerful resource for you in the care of your patients!

Very Best Regards,


John D. Day, MD, FHRS, FACC
The Journal of Innovations in Cardiac Rhythm Management
Director of Heart Rhythm Services
Intermountain Medical Center
Salt Lake City, UT


  1. Di Biase L, Gaita F, Toso E, et al. Does the peri-procedural Antiocoagulation Management for AF Affect the Prevalence of Silent thrombeoembolic Lesion detected by Diffusion Cerebral Magnetic Resonance Imaging (dMRI) in patients undergoing radiofrequency AF ablation with open Irrigated catheters? Results from a prospective multicenter study. Heart Rhythm 2014. [CrossRef] [PubMed]