Online first
Original Article
Published online: 2024-11-26
Silent cerebral ischemic lesions in ablation-naïve patients with non-valvular atrial fibrillation: does the pulmonary vein anatomy matter?
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, 2, 1, 34, 14, 14, 5, 2, 6, 7, 6, 8
, 2, 1, 34, 14, 14, 5, 2, 6, 7, 6, 8
DOI: 10.5603/cj.99142
Pubmed: 39589069
Abstract
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.
Keywords: atrial fibrillationsilent cerebral infarctssilent stroke
References
- Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991; 22(8): 983–988.
- Friberg L, Hammar N, Rosenqvist M. Stroke in paroxysmal atrial fibrillation: report from the Stockholm Cohort of Atrial Fibrillation. Eur Heart J. 2010; 31(8): 967–975.
- Vermeer SE, Koudstaal PJ, Oudkerk M, et al. Prevalence and risk factors of silent brain infarcts in the population-based Rotterdam Scan Study. Stroke. 2002; 33(1): 21–25.
- Vermeer SE, Prins ND, den Heijer T, et al. Silent brain infarcts and the risk of dementia and cognitive decline. N Engl J Med. 2003; 348(13): 1215–1222.
- van Veluw SJ, Shih AY, Smith EE, et al. Detection, risk factors, and functional consequences of cerebral microinfarcts. Lancet Neurol. 2017; 16(9): 730–740.
- Carmine D, Aeschbacher S, Coslovsky M, et al. Swiss-AF Study Investigators. Relationships of overt and silent brain lesions with cognitive function in patients with atrial fibrillation. J Am Coll Cardiol. 2019; 73(9): 989–999.
- Manolis TA, Manolis AA, Apostolopoulos EJ, et al. Atrial fibrillation and cognitive impairment: an associated burden or burden by association? Angiology. 2020; 71(6): 498–519.
- Dagres N, Chao TF, Fenelon G, et al. European Heart Rhythm Association (EHRA)/Heart Rhythm Society (HRS)/Asia Pacific Heart Rhythm Society (APHRS)/Latin American Heart Rhythm Society (LAHRS) expert consensus on arrhythmias and cognitive function: what is the best practice? Heart Rhythm. 2018; 15(6): e37–e60.
- Lip GYH, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010; 137(2): 263–272.
- Gaita F, Corsinovi L, Anselmino M, et al. Prevalence of silent cerebral ischemia in paroxysmal and persistent atrial fibrillation and correlation with cognitive function. J Am Coll Cardiol. 2013; 62(21): 1990–1997.
- Wieczorek J, Mizia-Stec K, Lasek-Bal A, et al. CHA2DS2-Vasc score, age and body mass index as the main risk factors of hyperintense brain lesions in asymptomatic patients with paroxysmal non-valvular atrial fibrillation. Int J Cardiol. 2016; 215: 476–481.
- Miki K, Nakano M, Aizawa K, et al. Risk factors and localization of silent cerebral infarction in patients with atrial fibrillation. Heart Rhythm. 2019; 16(9): 1305–1313.
- Rydén L, Sacuiu S, Wetterberg H, et al. Atrial fibrillation, stroke, and silent cerebrovascular disease: a population-based MRI study. Neurology. 2021; 97(16): e1608–e1619.
- Wieczorek J, Mizia-Stec K, Lasek-Bal A, et al. Hyperintense brain lesions in asymptomatic low risk patients with paroxysmal atrial fibrillation undergoing radiofrequency pulmonary vein isolation. J Clin Med. 2021; 10(4).
- Herm J, Schurig J, Martinek MR, et al. MRI-detected brain lesions in AF patients without further stroke risk factors undergoing ablation — a retrospective analysis of prospective studies. BMC Cardiovasc Disord. 2019; 19(1): 58.
- Sanna T, Diener HC, Passman RS, et al. CRYSTAL AF Investigators. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014; 370(26): 2478–2486.
- Wańkowicz P, Nowacki P, Gołąb-Janowska M, et al. Atrial fibrillation risk factors in patients with ischemic stroke. Arch Med Sci. 2021; 17(1): 19–24.
- Ble M, Benito B, Cuadrado-Godia E, et al. Left atrium assessment by speckle tracking echocardiography in cryptogenic stroke: seeking silent atrial fibrillation. J Clin Med. 2021; 10(16): 3501.
- Freedman B, Camm J, Calkins H, et al. AF-Screen Collaborators. Screening for Atrial Fibrillation: a report of the AF-SCREEN International Collaboration. Circulation. 2017; 135(19): 1851–1867.
- Mitręga K, Średniawa B, Sokal AYH, et al. The effectiveness of atrial fibrillation identification using noninvasive long-term electrocardiographic monitoring system (NOMED-AF TECH). Pol Arch Intern Med. 2023; 133(7–8): 16450.
- Gupta A, Giambrone AE, Gialdini G, et al. Silent brain infarction and risk of future stroke: a systematic review and meta-analysis. Stroke. 2016; 47(3): 719–725.
- Latacz P, Simka M, Bryll A, et al. Cerebral ischemic lesions on diffusion-weighted magnetic resonance imaging after carotid eversion endarterectomy vs carotid stenting with a proximal protection device: results of a randomized prospective trial. Pol Arch Intern Med. 2019; 129(7–8): 563–566.
- Głowniak A, Janczarek M, Tarkowski A, et al. Silent cerebral infarcts following left-sided accessory pathway ablation in Wolff-Parkinson-White (WPW) syndrome: a preliminary report. Med Sci Monit. 2019; 25: 1336–1341.
- Glowniak A, Tarkowski A, Janczarek M, et al. Silent cerebral infarcts following pulmonary vein isolation with different atrial fibrillation ablation techniques — incidence and risk factors. Arch Med Sci. 2022; 18(3): 632–638.
- Vermeer SE, Longstreth WT, Koudstaal PJ. Silent brain infarcts: a systematic review. Lancet Neurol. 2007; 6(7): 611–619.
- Escudero-Martínez I, Ocete RF, Mancha F, et al. Prevalence and risk factors of silent brain infarcts in patients with AF detected by 3T-MRI. J Neurol. 2020; 267(9): 2675–2682.
- Fanning JP, Wong AA, Fraser JF. The epidemiology of silent brain infarction: a systematic review of population-based cohorts. BMC Med. 2014; 12: 119.
- Steiner F, Meyre PB, Aeschbacher S, et al. Swiss-AF Investigators. Association of the CHA2D(S2)-VASc score and its components with overt and silent ischemic brain lesions in patients with atrial fibrillation. Front Neurol. 2020; 11: 609234.
- Bretzman JP, Tseng AS, Graff-Radford J, et al. Silent cerebral infarcts in patients with atrial fibrillation: Clinical implications of an imaging-adjusted CHA2DS2-VASc score. Cardiol J. 2022; 29(5): 766–772.
- De Marchis GM, Krisai P, Werlen L, et al. Swiss-AF Investigators. Biomarker, imaging, and clinical factors associated with overt and covert stroke in patients with atrial fibrillation. Stroke. 2023; 54(10): 2542–2551.
- Kim SH, Shin DW, Yun JM, et al. Kidney dysfunction and silent brain infarction in generally healthy adults. J Neurol Sci. 2017; 379: 89–93.
- Matusik PT, Heleniak Z, Papuga-Szela E, et al. Chronic kidney disease and its impact on a prothrombotic state in patients with atrial fibrillation. J Clin Med. 2020; 9(8): 2476.
- Matusik PT, Małecka B, Lelakowski J, et al. Association of NT-proBNP and GDF-15 with markers of a prothrombotic state in patients with atrial fibrillation off anticoagulation. Clin Res Cardiol. 2020; 109(4): 426–434.
- Altinkaynak D, Koktener A. Evaluation of pulmonary venous variations in a large cohort : Multidetector computed tomography study with new variations. Wien Klin Wochenschr. 2019; 131(19–20): 475–484.
- Cappa R, Du J, Carrera JF, et al. Ischemic stroke secondary to paradoxical embolism through a pulmonary arteriovenous malformation: case report and review of the literature. J Stroke Cerebrovasc Dis. 2018; 27(7): e125–e127.
- Tsao HM, Wu MH, Yu WC, et al. Role of right middle pulmonary vein in patients with paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 2001; 12(12): 1353–1357.
- Woźniak-Skowerska I, Skowerski M, Wnuk-Wojnar A, et al. Comparison of pulmonary veins anatomy in patients with and without atrial fibrillation: analysis by multislice tomography. Int J Cardiol. 2011; 146(2): 181–185.
- Bittner A, Mönnig G, Vagt AJ, et al. Pulmonary vein variants predispose to atrial fibrillation: a case-control study using multislice contrast-enhanced computed tomography. Europace. 2011; 13(10): 1394–1400.
- Skowerski M, Wozniak-Skowerska I, Hoffmann A, et al. Pulmonary vein anatomy variants as a biomarker of atrial fibrillation — CT angiography evaluation. BMC Cardiovasc Disord. 2018; 18(1): 146.
- Killeen RP, O'Connor SA, Keane D, et al. Ectopic focus in an accessory left atrial appendage: radiofrequency ablation of refractory atrial fibrillation. Circulation. 2009; 120(8): e60–e62.
- Tan C, Han W, Liu X, et al. Electrophysiological characteristics of left atrial diverticulum in patients with atrial fibrillation: electrograms, impedance and clinical implications. Int J Cardiol. 2014; 176(1): 48–54.
- Hołda MK, Koziej M, Wszołek K, et al. Left atrial accessory appendages, diverticula, and left-sided septal pouch in multi-slice computed tomography. Association with atrial fibrillation and cerebrovascular accidents. Int J Cardiol. 2017; 244: 163–168.
