Uninterrupted Anticoagulation to Reduce Embolic Stroke During Catheter Ablation of Atrial Fibrillation

January 01, 2018 —
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Problem To Solve

Catheter ablation of atrial fibrillation is associated with the potential risk of periprocedural stroke, which can range between 1% and 5%.

Our Approach

We developed a prospective database to evaluate the prevalence of stroke over time and to assess whether the periprocedural anticoagulation strategy and use of open irrigated ablation catheter have resulted in a reduction of this complication.

Study
 
We collected outcome data from 6454 consecutive patients in 9 centers on stroke/transient ischemic attack and bleeding complications during and early after performing the same ablation procedure with the same anticoagulation protocol.


Patients were divided into 3 groups

●     Group 1: Ablation with an 8-mm catheter off warfarin (n=2488)

●     Group 2: Ablation with an open irrigated catheter off warfarin (n=1348)

●     Group 3: Ablation with an open irrigated catheter on warfarin (n=2618)


Results

●     Periprocedural stroke/transient ischemic attack occurred in 27 patients (1.1%) in Group 1 and 12 patients (0.9%) in Group 2

●     No stroke/transient ischemic attack was reported in Group 3

●     Despite a higher prevalence of nonparoxysmal atrial fibrillation and more patients with CHADS2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score >2

●     Complications among groups 1, 2, and 3 were equally distributed. They included major bleeding (10 [0.4%], 11 [0.8%], and 10 [0.4%], respectively; P>0.05) and pericardial effusion (11 [0.4%], 11 [0.8%], and 12 [0.5%]; P>0.05)


Conclusion

The combination of an open irrigated ablation catheter and periprocedural therapeutic anticoagulation with warfarin reduce the risk of periprocedural stroke without increasing the risk of pericardial effusion or other bleeding complications. Likewise, we investigated that an uninterrupted DOACs strategy for CA of NVAF appears to be as safe as uninterrupted VKA without a significantly increased risk of minor or major bleeding events. There was a trend favouring DOACs in terms of major bleeding. Given their ease of use, fewer drug interactions and a similar security and effectiveness profile, DOACs should be considered first line therapy in patients undergoing CA for NVAF. 



Di Biase L, Burkhardt JD, Mohanty P, Sanchez J, Horton R, Gallinghouse GJ et al. Periprocedural stroke and management of major bleeding complications in patients undergoing catheter ablation of atrial fibrillation: the impact of periprocedural therapeutic international normalized ratio. Circulation. 2010;121:2550–6.

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Romero J, Cerrud-Rodriguez RC, Diaz JC, Michaud GF, Taveras J, Alviz I, Grupposo V, Cerna L, Avendano R, Kumar S, Kirchhof P, Natale A and Di Biase L. Uninterrupted direct oral anticoagulants vs. uninterrupted vitamin K antagonists during catheter ablation of non-valvular atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials. Europace. 2018.

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