1161Efficacy of non-vitamin k antagonist oral anticoagulants for perioperative complication in patients with atrial fibrillation undergoing catheter ablation

Abstract Aims Although a recent expert consensus statement has recommended periprocedural uninterrupted (UI) non-vitamin K antagonist oral anticoagulants (NOACs) during catheter ablation of atrial fibrillation (AF) as a Class I indication, there have been no clear randomized trials. We investigated the safety and efficacy of UI, procedure day single-dose skipped (SDS), and 24-hour skipped (24S) NOACs in patients undergoing AF ablation. Methods and results In this prospective, open-label, randomized multicentre trial, 326 patients (75% male, 58 ± 11 years old) scheduled for AF catheter ablation were randomly assigned in a 1:1:1 ratio to UI, SDS, and 24S at three tertiary hospitals. Bridging with low molecular weight heparin was carried out in the patients with persistent AF who were assigned to the 24S group. Dabigatran, rivaroxaban, and apixaban were assigned in order after randomization. The primary endpoint was the incidence of bleeding events within 1 month after ablation. The secondary endpoints included thrombo-embolic and other procedure-related complications. The intra-procedural heparin requirement was higher in the 24S group than others (P < 0.001), and the mean activated clotting time was comparable among the groups (P = 0.139). The incidence of major bleeding up to 1 month after ablation and a post-procedural reduction in the haemoglobin levels did not significantly differ among the treatment groups and different NOACs (P > 0.05). There were no fatal events or thrombo-embolic complications in all the three groups. Conclusion In patients undergoing AF ablation, UI NOACs and SDS or double dose skipped NOACs had a comparable efficacy and safety, regardless of the type of NOAC.

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Meta-Analysis of Safety and Efficacy of Uninterrupted Non–Vitamin K Antagonist Oral Anticoagulants Versus Vitamin K Antagonists for Catheter Ablation of Atrial Fibrillation

The American Journal of Cardiology ◽

10.1016/j.amjcard.2017.07.096 ◽

2017 ◽

Vol 120 (10) ◽

pp. 1830-1836 ◽

Cited By ~ 5

Author(s):

Akram Y. Elgendy ◽

Dhruv Mahtta ◽

Amr F. Barakat ◽

Ahmed Abuzaid ◽

Ahmad Mahmoud ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Vitamin K ◽

Meta Analysis ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Safety And Efficacy

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Periprocedural Complications in Patients Undergoing Catheter Ablation of Atrial Fibrillation Without Discontinuation of a Vitamin K Antagonist and Direct Oral Anticoagulants

Circulation Journal ◽

10.1253/circj.cj-17-1114 ◽

2018 ◽

Vol 82 (6) ◽

pp. 1552-1557 ◽

Cited By ~ 6

Author(s):

Toshiya Kojima ◽

Katsuhito Fujiu ◽

Nobuaki Fukuma ◽

Hiroshi Matsunaga ◽

Tsukasa Oshima ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Vitamin K ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Vitamin K Antagonist

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Management of Intraprocedural Anticoagulation in Patients on Non-Vitamin K Antagonist Oral Anticoagulants Undergoing Catheter Ablation for Atrial Fibrillation

Circulation ◽

10.1161/circulationaha.117.033326 ◽

2018 ◽

Vol 138 (6) ◽

pp. 627-633 ◽

Cited By ~ 7

Author(s):

Anne-Céline Martin ◽

Anne Godier ◽

Kumar Narayanan ◽

David M. Smadja ◽

Eloi Marijon

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Unfractionated Heparin ◽

Vitamin K ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Clotting Time ◽

Anticoagulation Management ◽

Activated Clotting Time

Catheter ablation has gained a prominent role in the management of atrial fibrillation (AF), with recent data providing positive evidence on hard outcomes, including hospitalization and mortality. Ablation, however, exposes the patient to a rather unique situation, combining risks for both major bleeding and thromboembolic events. In this setting, the critical importance of rigorous anticoagulation during the procedure has been underlined, and the latest international guidelines now recommend performing AF catheter ablation with uninterrupted non-vitamin K antagonist oral anticoagulants (NOACs) and concomitant administration of unfractionated heparin adjusted to achieve and maintain a target activated clotting time of ≥300 seconds. Whereas observational studies and randomized controlled trials support the safety and efficacy of uninterrupted NOAC strategy for AF catheter ablation, recent experiences have questioned this point, showing a greater unfractionated heparin requirement in NOAC-treated patients compared with vitamin K antagonists–treated patients to achieve the target activated clotting time. Important gaps in evidence regarding optimal intraprocedural anticoagulation management need to be acknowledged. A thorough appreciation of the physiology of anticoagulation during AF catheter ablation and the relevant differences between vitamin K antagonists and NOACs is required, while also understanding the limitations of activated clotting time measurement with regard to accurate intraprocedural anticogulation monitoring. This review aims to provide a critical look at this relatively ignored aspect of AF catheter ablation, especially pitfalls in NOAC monitoring, and to identify gaps in knowledge that need to be addressed in the near future.

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