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Increased number of cerebral emboli during percutaneous endocardial pulmonary vein isolation versus a thoracoscopic epicardial approach

^a Academic Hospital Maastricht, Department of Cardiothoracic Surgery, Maastricht, The Netherlands
^b Unité de rythmologie de Mont-Godinne, Universite de Louvain (UCL), Yvoir, Belgium
^c Academic Hospital Maastricht, Department of Cardiology, Maastricht, The Netherlands
^d Academic Hospital Maastricht, Department of Clinical Neurophysiology, Maastricht, The Netherlands

Received 16 January 2009; received in revised form 6 May 2009; accepted 6 May 2009.

^_* Corresponding author. Address: Department of Cardiothoracic Surgery, Academic Hospital Maastricht, P. Debyelaan 25, 6229HX, Maastricht, The Netherlands. Tel.: +31 43 3875070; fax: +31 43 3875993. (Email: l.sauren{at}ctc.unimaas.nl).

Objective: Pulmonary vein isolation (PVI) using ablation energy appears an effective treatment for atrial fibrillation (AF) with a success rate of approximately 80%. However, post-procedural neurological complications still occur in 0.5–10% of all patients undergoing PVI, presumably due to embolism. Therefore, we investigated the occurrence of cerebral micro-embolic signals (MES) as a surrogate marker for the risk of neurological impairment of two different PVI methods: (1) percutaneous endocardial radio-frequency (RF) ablation and (2) thoracoscopic epicardial ablation using RF energy. Methods: Ten patients (eight persistent AF and two paroxysmal AF) underwent a minimally invasive thoracoscopic epicardial (EPI) RF ablation and 10 patients (one persistent AF and nine paroxysmal AF) underwent a percutaneous endocardial (ENDO) isolation. Transcranial Doppler (TCD) was used to detect an MES in the middle cerebral arteries. Results: An average of 5 (±6) MES were detected during epicardial PVI procedure versus 3908 (±2816) MES during percutaneous endocardial PVI procedure. During the ablation application period, respectively, 1 (±1) and 2566 (±2296) cerebral MES were detected. Conclusions: Cerebral micro-emboli during epicardial ablation are almost absent when compared to the thousands of emboli measured during percutaneous endocardial ablation.

Key Words: Transcranial Doppler • Cerebral emboli • Pulmonary vein isolation • Ablation