The Sound of Silence
How Much Noise Should We Make About Postablation Silent Strokes?
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Article, see p 867
Catheter ablation has become an essential therapeutic option for the treatment of ventricular arrhythmias. For premature ventricular complex (PVC)/ventricular tachycardia (VT) ablation in structurally normal hearts, recently reported success rates are as high as 80% for right ventricular outflow tract ablation, and 60% to 100% for left-sided ablation.1 Procedural safety and efficacy have improved with better understanding of surface ECG predictors of PVC origin location, refined electroanatomic mapping techniques, evermore precise electroanatomic activation maps to localize PVC origins, automated techniques to quantify the fidelity of pace-mapping surface QRS morphologies, improved ablation technology, and intracardiac ultrasound.1 Although these advancements might lead us to believe we have entered a golden age for interventional electrophysiology, we as electrophysiologists and cardiologists need to continue our vigilance for serious complications arising from these invasive procedures.
In this issue of Circulation, Whitman et al2 evaluate the incidence of subclinical brain emboli in a small series of patients with structurally normal hearts undergoing endocardial catheter ablation for PVCs and VT. Electrophysiologists frequently map and ablate in the left ventricular (LV) endocardial and aortic root spaces,1,3,4 with an assumption that, with proper intravenous systemic anticoagulation, the risk of systemic embolization phenomenon is acceptably low. In addition, with transseptal procedures, the risk of air or thrombus entry to the systemic circulation via the transseptal sheath is minimized through continuous saline flush through the long sheaths, or by retracting the sheath back to the right atrium. More recently, with the near-universal adoption of open-irrigated catheters, it is assumed that the risks of catheter char, coagulum, or thrombus are mitigated, although there are few clinical data to support this claim.
It turns out that we know very little about whether any of these measures are truly effective in minimizing …