Brain Emboli, Not Transseptal Puncture, Linked to Post-Ablation Visual Auras

In patients undergoing catheter ablation for ventricular arrhythmias, the occurrence of migraine-related visual auras is associated with post-procedural brain emboli, particularly in the occipital and parietal lobes, rather than the method of catheter access, according to findings published in Heart Rhythm.

The Transseptal vs Retrograde Aortic Ventricular Entry to Reduce Systemic Emboli trial was a prospective, multicenter, randomized controlled study (ClinicalTrials.gov Identifier: NCT03946072) designed to determine whether transseptal puncture contributes to visual aura symptoms or if these events are instead caused by silent cerebral emboli.

A total of 146 patients undergoing left ventricular endocardial ablation were randomized to transseptal (n=74) or retrograde aortic (n=72) access. All participants underwent brain magnetic resonance imaging (MRI) on post-procedure day 1, and migraine symptoms were assessed at baseline and again at a median of 38 days using a validated questionnaire. A total of 63 from the transseptal group and 57 from the retrograde aortic group completed the 1-month migraine follow-up.

Visual auras were reported by 16% of patients in the transseptal group (n=10) and 14% in the retrograde group (n=8; P =.78). Of those who had visual auras, the mean (SD) age was 60 (15) years, 44% were women, and 94% were White. Those with no visual auras were a mean (SD) age of 64 (12) years, 19% were women, and 85% were White. No significant differences in other migraine symptoms, such as headache, light/sound sensitivity, or nausea, were observed between groups.

However, participants with brain emboli located in the occipital or parietal lobes were significantly more likely to report visual auras than those without (38% vs 11%; P <.01). In multivariable analysis adjusted for age, sex, body mass index, and baseline visual aura history, emboli in these visual-processing regions were independently associated with a 12-fold increased odds of developing post-procedural visual auras.

Additional analyses confirmed this relationship after accounting for missing data using multiple imputation. Pre-procedural and post-procedural anticoagulation patterns did not differ significantly between groups, nor did the presence of emboli correlate with headache alone, neurocognitive decline, or symptoms persisting at 6 months.

Among the 58 patients with baseline MRI, no acute emboli were detected prior to the procedure, and post-procedural emboli in the occipital or parietal lobes remained associated with visual auras. A subgroup analysis in patients without prior visual aura history showed a similar trend, though statistical significance was not reached (P =.09).

Study limitations include self-reported migraine data, a 20% non-completion rate for the 1-month questionnaire, limited generalizability beyond the ventricular ablation setting, and insufficient power to detect small differences between access strategies.

“These findings suggest that common migraine symptoms may be attributable to acute brain emboli and not anything due to inter-atrial shunting,” the study authors concluded.

Disclosures: This research was supported by the Patient Centered Outcomes Research Institute. Multiple study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.