Left Ventricular Entry to Reduce Brain Lesions During Catheter Ablation: A Randomized Trial
Abstract
BACKGROUND: Catheter ablation of ventricular arrhythmias, one of the most rapidly growing procedures in cardiac electrophysiology, is associated with magnetic resonance imaging–detected brain lesions in more than half of cases. Although a retrograde aortic approach is conventional, modern tools enable entry through a transseptal approach that may avoid embolization of debris from the arterial system. We sought to test the hypothesis that a transseptal puncture would mitigate brain injury compared with a retrograde aortic approach. METHODS: The TRAVERSE trial (Transseptal Versus Retrograde Aortic Ventricular Entry to Reduce Systemic Emboli) was a multicenter randomized controlled comparative effectiveness trial. Patients with left ventricular arrhythmias undergoing catheter ablation procedures were randomly assigned to a transseptal puncture approach compared (1:1) with a retrograde aortic approach. The primary outcome was the presence of an acute brain lesion detected by magnetic resonance imaging. Secondary outcomes included clinically manifest complications, procedural efficacy, and 6-month neurocognitive assessments. RESULTS: Among the 62 patients randomly assigned to a retrograde aortic approach with postoperative brain magnetic resonance imaging, 28 (45%) exhibited an acute brain lesion compared with 19 of the 69 (28%) of those randomized to a transseptal puncture ( P =0.036). No differences in clinically manifest complications or procedural efficacy were observed. More patients in the retrograde aortic arm were categorized as having a high likelihood of cognitive impairment at 6 months (33% compared with 19% of those in the transseptal arm), but substantial loss to follow-up was present. CONCLUSIONS: Among patients undergoing left ventricular catheter ablation procedures, a transseptal approach reduced the risk of acute brain lesions by nearly half compared with a retrograde aortic approach without sacrificing safety or efficacy. Given a likely embolic pathogenesis, the brain magnetic resonance imaging findings may reflect a propensity to other organ damage; these findings may extend to other procedures requiring left ventricular entry. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03946072.
Article Details
Authors (35)
Gregory M. Marcus
Division of Cardiology, University of California, San Francisco, San Francisco
Roderick Tung
Division of Cardiology (G.M.M., E.P.G., H.H., A.L., J.M., G.W., K.C., M.Y., G.M.), University of California, San Francisco.
Edward P. Gerstenfeld
University of California San Francisco (E.P.G.).
Trisha F. Hue
Department of Epidemiology and Biostatistics (T.F.H., F.L.), University of California, San Francisco.
Feng Lin
Jing Cheng
J. Peter Weiss
Division of Cardiology, University of Arizona College of Medicine–Phoenix, Banner – University Medical Center (R.T., J.P.W.).
Wendy S. Tzou
Division of Cardiology, University of Colorado Anschutz Medical Center, Aurora (W.S.T.).
Henry Hsia
Division of Cardiology (G.M.M., E.P.G., H.H., A.L., J.M., G.W., K.C., M.Y., G.M.), University of California, San Francisco.
Ashkan Ehdaie
Division of Cardiology (G.M.M., E.P.G., H.H., A.L., J.M., G.W., K.C., M.Y., G.M.), University of California, San Francisco.
Daniel H. Cooper
Cardiovascular Division, Washington University School of Medicine, St. Louis (D.H.C.).
T. Jared Bunch
Division of Cardiovascular Medicine, University of Utah, Salt Lake City (T.J.B.).
Jeffrey Arkles
University of Pennsylvania, Philadelphia, Pennsylvania, United States
Babak Nazer
University of Washington, Seattle, Washington, United States
Adam Lee
Division of Cardiology (G.M.M., E.P.G., H.H., A.L., J.M., G.W., K.C., M.Y., G.M.), University of California, San Francisco.
Alexios Hadjis
Division of Cardiology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Canada (A.H.).
Duy T. Nguyen
Mihail G. Chelu
Department of Medicine–Cardiology, Cardiovascular Research Institute, Baylor College of Medicine and Texas Heart Institute at Baylor St. Luke’s Medical Center, Houston (M.G.C.).
Joshua Moss
Division of Cardiology (G.M.M., E.P.G., H.H., A.L., J.M., G.W., K.C., M.Y., G.M.), University of California, San Francisco.
Jonathan C. Hsu
Division of Cardiology, University of California, San Diego (J.C.H.).
Miguel Valderrabano
Houston Methodist Hospital, Houston, Texas, United States
Prashant D. Bhave
Department of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC (P.D.B.).
Andrew D. Beaser
Section of Cardiology, University of Chicago, IL (A.D.B.).
Arvindh Kanagasundram
Vanderbilt University, Nashville
Oussama Wazni
Cleveland Clinic, Cleveland, Ohio, United States
Jason Bradfield
Cardiac Arrhythmia Center, University of California, Los Angeles (J.B.)
Grace Wall
Division of Cardiology (G.M.M., E.P.G., H.H., A.L., J.M., G.W., K.C., M.Y., G.M.), University of California, San Francisco.
Kathleen Chang
Division of Cardiology (G.M.M., E.P.G., H.H., A.L., J.M., G.W., K.C., M.Y., G.M.), University of California, San Francisco.
Michelle Yang
Department of Psychology
Gabrielle Montenegro
Division of Cardiology (G.M.M., E.P.G., H.H., A.L., J.M., G.W., K.C., M.Y., G.M.), University of California, San Francisco.
Sabrina Jarrott
Department of Neurology (S.J., J.H.K., A.S.K.), University of California, San Francisco.
Joel H. Kramer
Anthony S. Kim
Department of Neurology (S.J., J.H.K., A.S.K.), University of California, San Francisco.
Yvonne M. Morris
Patient Author (Y.M.M.), University of California, San Francisco.
William P. Dillon
Department of Radiology and Biomedical Imaging (W.P.D.), University of California, San Francisco.