Symptomatic embolisms after AF ablation: new insights on outcomes and predictors

Registry data determined an overall incidence of 0.16 embolisms per ablation procedure for left atrial (LA) ablation for atrial fibrillation (AF). The result identified different predictors of variations in incidence, including the type of arrhythmia or the procedure volume of the performing centre.

The low overall incidence of embolic complications after LA ablation, makes the subject difficult for randomised trials to investigate. This led to the design of an international multicentre registry study aiming to collect insights into incidence, clinical profiles, influence on ablation strategy used and outcomes. The study included 182 centres in 53 countries with personally invited investigators [1].

The registry included a reference population (RP) consisting of all 304949 ablations (AF and LA flutter) between 2017 and 2023, as well as 491 included cases of symptomatic arterial embolisms happening within the first month post-ablation. In the RP, 53% of patients had paroxysmal AF and 68% received their first ablation, performed in 71% with radiofrequency (RF), 25% cryoballoon (CB), 4% pulsed field ablation (PFA), <1% laser balloon. The corresponding characteristics of the embolism group showed 46% of paroxysmal AF, 79% of first ablations and the use of RF in 69%, CB in 23%, PFA in 6% and laser in 2%. Dr Sergio Castrejon (La Paz University Hospital, Madrid, Spain) commented that cases with higher baseline risk somewhat clustered in the RF group in which procedures tended to be longer and had more ablations beyond the primary veins.

The overall incidence was 0.16 cases/procedure. Looking at the time-to-event, 78% of embolism were diagnosed in under 72 hours after the ablation. “Notably, 15% of cases were detected during the procedure,” Dr Castrejón informed. Neurologic diagnoses were stroke in 324 patients and transient ischaemic attack (TIA) in 137, with limb weakness, aphasia and dysarthria as most common symptoms. The underlying cause was an occlusion of the middle cerebral artery in 53.4% of cases. Dr Castrejón pointed outthat most symptoms were severe. There were also 34 cases of peripheral embolisms, and 3 patients had a combination of brain and coronary embolisms. “In the follow-up after 3 months, which was available in 94% of patients, roughly 40% had some degree of neurological disability and almost 3% died directly as a consequence of the embolism,” Dr Castrejón stated [1].

A further analysis also identified several predictors. Patients ablated for non-paroxysmal AF had a higher incidence of embolisms than those with paroxysmal AF (P<0.001). Furthermore, centres with fewer than 92 procedures per year were linked to higher embolism-incidence. Finally, in comparisons of different energy sources for ablation, incidence of embolisms was higher with laser vs the others (P<0.001) and thermal ablation vs PFA (P=0.02), respectively.

1. Castrejón S, et al. Worldwide incidence, management and outcome of systemic embolism following atrial fibrillation ablation: preliminary results from the EMBOL-AF registry. Late-breaking science 4, EHRA 2025, 30 March-01 April, Vienna, Austria.

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Posted on 6 May 20256 May 2025