Ischemic stroke or systemic embolism after transseptal ablation of arrhythmias in patients with cardiac implantable electronic devices

Malini Madhavan, Xiaoxi Yao, Lindsey R. Sangaralingham, Samuel J Asirvatham, Paul Andrew Friedman, Christopher J. McLeod, Alan M. Sugrue, Christopher V. DeSimone, Peter Noseworthy

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Background-Incidental mobile thrombi are commonly found on endovascular leads of cardiac implantable electronic devices (CIEDs). Transseptal puncture for catheter ablation of arrhythmia poses a risk for paradoxical embolism. We examined risk of ischemic stroke, transient ischemic attack (TIA), or systemic embolism after transseptal ablation in patients with and without CIEDs. Methods and Results-Using a national administrative claims database, 31 720 patients who underwent a transseptal catheter ablation between January 2004 and September 2014 were identified. Two propensity-matched cohorts were created by matching demographic variables, administrative variables, Charlson Comorbidity Index, CHA2DS2-Vasc score, and year and indication for ablation (5533 and 11 300 patients with and without CIEDs). Incidence rates and Cox proportional hazards models were used to estimate risk of ischemic stroke, TIA, or systemic embolism for patients with and without CIEDs. Impact of oral anticoagulation (OAC) use on the endpoint was examined. Over a mean follow-up of 2.1 years, the incidence of the combined endpoint was 1.9 per 100 person-years in patients with CIEDs and 1.5 per 100 person-years in patients without CIEDs (P=0.03). Among patients not on OAC, presence of a cardiac device was associated with an increased risk (hazard ratio [HR], 1.71 [1.24-2.35]; P<0.01), whereas there was no association noted among patients treated with OAC (HR, 0.98 [0.75-1.28]). Conclusion-CIEDs are associated with an increased risk of stroke, TIA, or systemic embolism after transseptal ablation, but this risk is attenuated with postablation OAC use. Role of anticoagulation post-transseptal ablation in patients with CIED warrants further investigation.

Original languageEnglish (US)
Article numbere003163
JournalJournal of the American Heart Association
Volume5
Issue number4
DOIs
StatePublished - 2016

Fingerprint

Embolism
Cardiac Arrhythmias
Stroke
Equipment and Supplies
Transient Ischemic Attack
Catheter Ablation
Paradoxical Embolism
Incidence
Punctures
Proportional Hazards Models
Comorbidity
Thrombosis
Odds Ratio
Demography
Databases

Keywords

  • Atrial fibrillation
  • Cardiac ablation
  • Stroke
  • Systemic embolism
  • Transseptal puncture

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Ischemic stroke or systemic embolism after transseptal ablation of arrhythmias in patients with cardiac implantable electronic devices. / Madhavan, Malini; Yao, Xiaoxi; Sangaralingham, Lindsey R.; Asirvatham, Samuel J; Friedman, Paul Andrew; McLeod, Christopher J.; Sugrue, Alan M.; DeSimone, Christopher V.; Noseworthy, Peter.

In: Journal of the American Heart Association, Vol. 5, No. 4, e003163, 2016.

Research output: Contribution to journalArticle

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abstract = "Background-Incidental mobile thrombi are commonly found on endovascular leads of cardiac implantable electronic devices (CIEDs). Transseptal puncture for catheter ablation of arrhythmia poses a risk for paradoxical embolism. We examined risk of ischemic stroke, transient ischemic attack (TIA), or systemic embolism after transseptal ablation in patients with and without CIEDs. Methods and Results-Using a national administrative claims database, 31 720 patients who underwent a transseptal catheter ablation between January 2004 and September 2014 were identified. Two propensity-matched cohorts were created by matching demographic variables, administrative variables, Charlson Comorbidity Index, CHA2DS2-Vasc score, and year and indication for ablation (5533 and 11 300 patients with and without CIEDs). Incidence rates and Cox proportional hazards models were used to estimate risk of ischemic stroke, TIA, or systemic embolism for patients with and without CIEDs. Impact of oral anticoagulation (OAC) use on the endpoint was examined. Over a mean follow-up of 2.1 years, the incidence of the combined endpoint was 1.9 per 100 person-years in patients with CIEDs and 1.5 per 100 person-years in patients without CIEDs (P=0.03). Among patients not on OAC, presence of a cardiac device was associated with an increased risk (hazard ratio [HR], 1.71 [1.24-2.35]; P<0.01), whereas there was no association noted among patients treated with OAC (HR, 0.98 [0.75-1.28]). Conclusion-CIEDs are associated with an increased risk of stroke, TIA, or systemic embolism after transseptal ablation, but this risk is attenuated with postablation OAC use. Role of anticoagulation post-transseptal ablation in patients with CIED warrants further investigation.",
keywords = "Atrial fibrillation, Cardiac ablation, Stroke, Systemic embolism, Transseptal puncture",
author = "Malini Madhavan and Xiaoxi Yao and Sangaralingham, {Lindsey R.} and Asirvatham, {Samuel J} and Friedman, {Paul Andrew} and McLeod, {Christopher J.} and Sugrue, {Alan M.} and DeSimone, {Christopher V.} and Peter Noseworthy",
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T1 - Ischemic stroke or systemic embolism after transseptal ablation of arrhythmias in patients with cardiac implantable electronic devices

AU - Madhavan, Malini

AU - Yao, Xiaoxi

AU - Sangaralingham, Lindsey R.

AU - Asirvatham, Samuel J

AU - Friedman, Paul Andrew

AU - McLeod, Christopher J.

AU - Sugrue, Alan M.

AU - DeSimone, Christopher V.

AU - Noseworthy, Peter

PY - 2016

Y1 - 2016

N2 - Background-Incidental mobile thrombi are commonly found on endovascular leads of cardiac implantable electronic devices (CIEDs). Transseptal puncture for catheter ablation of arrhythmia poses a risk for paradoxical embolism. We examined risk of ischemic stroke, transient ischemic attack (TIA), or systemic embolism after transseptal ablation in patients with and without CIEDs. Methods and Results-Using a national administrative claims database, 31 720 patients who underwent a transseptal catheter ablation between January 2004 and September 2014 were identified. Two propensity-matched cohorts were created by matching demographic variables, administrative variables, Charlson Comorbidity Index, CHA2DS2-Vasc score, and year and indication for ablation (5533 and 11 300 patients with and without CIEDs). Incidence rates and Cox proportional hazards models were used to estimate risk of ischemic stroke, TIA, or systemic embolism for patients with and without CIEDs. Impact of oral anticoagulation (OAC) use on the endpoint was examined. Over a mean follow-up of 2.1 years, the incidence of the combined endpoint was 1.9 per 100 person-years in patients with CIEDs and 1.5 per 100 person-years in patients without CIEDs (P=0.03). Among patients not on OAC, presence of a cardiac device was associated with an increased risk (hazard ratio [HR], 1.71 [1.24-2.35]; P<0.01), whereas there was no association noted among patients treated with OAC (HR, 0.98 [0.75-1.28]). Conclusion-CIEDs are associated with an increased risk of stroke, TIA, or systemic embolism after transseptal ablation, but this risk is attenuated with postablation OAC use. Role of anticoagulation post-transseptal ablation in patients with CIED warrants further investigation.

AB - Background-Incidental mobile thrombi are commonly found on endovascular leads of cardiac implantable electronic devices (CIEDs). Transseptal puncture for catheter ablation of arrhythmia poses a risk for paradoxical embolism. We examined risk of ischemic stroke, transient ischemic attack (TIA), or systemic embolism after transseptal ablation in patients with and without CIEDs. Methods and Results-Using a national administrative claims database, 31 720 patients who underwent a transseptal catheter ablation between January 2004 and September 2014 were identified. Two propensity-matched cohorts were created by matching demographic variables, administrative variables, Charlson Comorbidity Index, CHA2DS2-Vasc score, and year and indication for ablation (5533 and 11 300 patients with and without CIEDs). Incidence rates and Cox proportional hazards models were used to estimate risk of ischemic stroke, TIA, or systemic embolism for patients with and without CIEDs. Impact of oral anticoagulation (OAC) use on the endpoint was examined. Over a mean follow-up of 2.1 years, the incidence of the combined endpoint was 1.9 per 100 person-years in patients with CIEDs and 1.5 per 100 person-years in patients without CIEDs (P=0.03). Among patients not on OAC, presence of a cardiac device was associated with an increased risk (hazard ratio [HR], 1.71 [1.24-2.35]; P<0.01), whereas there was no association noted among patients treated with OAC (HR, 0.98 [0.75-1.28]). Conclusion-CIEDs are associated with an increased risk of stroke, TIA, or systemic embolism after transseptal ablation, but this risk is attenuated with postablation OAC use. Role of anticoagulation post-transseptal ablation in patients with CIED warrants further investigation.

KW - Atrial fibrillation

KW - Cardiac ablation

KW - Stroke

KW - Systemic embolism

KW - Transseptal puncture

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