A More Specific Anticoagulation Regimen Is Required for Patients After the Cox-Maze Procedure

Abstract

Long-term management of oral anticoagulation (OAC) after ablation for atrial fibrillation (AF) is an ongoing challenge. Heart Rhythm Society (HRS) guidelines provide no specific recommendations for OAC after surgical ablation. The purpose of this study was to determine the necessity of OAC protocols after surgical ablation. Patients (N= 691) who underwent the Cox-Maze procedure with left atrial appendage (LAA) management were followed prospectively. All patients were discharged on OAC unless contraindicated. Cardiac rhythm, bleeding, and embolic stroke or transient ischemic attack (TIA), or both, were verified during follow-up. Over a mean follow-up of 47.3 ± 30.3 months, stroke/TIA was reported in 14 patients (5.1 cases per 1,000 person-years) and major bleeding events were found in 46 patients (16.9 cases per 1,000 person-years). Patients with major bleeding events had higher median CHADS2 (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack) scores (2 [range, 1-3] versus 1 [range, 1-2]; p= 0.012), but no association was found between incidence of stroke/TIA and median CHADS2 score (1 [range, 0-2.25] versus 1 [range, 1-2]; p=0.377). Patients with CHADS2 scores of 2 or greater had the same rates of stroke/TIA (p= 0.787) but a higher incidence of major bleeding (p= 0.009) as did patients with CHADS2 scores less than 2. Adjusting for OAC discontinuation and stable sinus rhythm, patients with CHADS2 scores of 2 or greater did not have higher stroke/TIA risk (hazard ratio [HR], 0.84; p= 0.759). Our results indicate that the decision to discontinue OAC after the Cox-Maze procedure should not be based solely on CHADS2 scores; rather, rhythm status, echocardiographic findings, and patient risk for bleeding should be considered. These findings underscore the need for an OAC protocol for patients who have undergone the Cox-Maze procedure with appropriate LAA management.