How minimally interrupted direct oral anticoagulants affect intraprocedural anticoagulation during atrial fibrillation ablation? Insights from a Japanese single-center retrospective study.

Masahiro Mizobuchi,Atsushi Funatsu,Shigeru Nakamura,Tomoko Kobayashi

doi:10.1002/joa3.12228

Abstract

BackgroundData are still lacking regarding the effects of minimally interrupted direct oral anticoagulants (MID) on the intensity of intraprocedural anticoagulation of atrial fibrillation (AF) ablation.MethodsA total of consecutive 269 patients who undergone AF ablation were eligible for the study. All oral anticoagulants (OACs) were discontinued just one dose before the procedure except warfarin. We assessed the total required dose of UFH and time‐to‐target ACT > 300 seconds (TTA) for each of direct oral anticoagulant (DOAC) groups compared with the uninterrupted warfarin group.ResultsDOACs were used in 86% of the patients in the present study (dabigatran group (DG)‐17%, rivaroxaban group (RG)‐30%, apixaban group (AG)‐29%, and edoxaban group (EG)‐10%). DG and EG used comparable dose of total UFH to WG (WG vs DG; 206 ± 53 U/kg vs 231 ± 63 U/kg; P = .664, vs EG; 239 ± 67 U/kg; P = .335), while RG and AG required higher total UFH (WG vs RG; 206 ± 53 U/kg vs 270 ± 63 U/kg; P < .001, vs AG; 263 ± 62 U/kg; P < .001). TTA was significantly longer in RG (RG:73 ± 28 minutes vs WG:51 ± 25 minutes; P = .001), AG (AG:64 ± 26 minutes vs WG:51 ± 25 minutes; P = .02), and EG (EG:67 ± 34 minutes vs WG:51 ± 25 minutes; P = .02) than WG, whereas DG was comparable to WG (DG:51 ± 29 minutes vs WG:51 ± 25 minutes; P = NS). Especially, only RG demonstrated significantly slower increase in ACT than WG (P = .013). In the multivariate analysis, warfarin or dabigatran use, age > 75 years, and body weight < 60 kg are clinical predictors for achieving TTA within 60 minutes (TTA‐60).ConclusionMID‐dabigatran was comparable to uninterrupted warfarin, whereas MID‐factor Xa inhibitors were not. MID is a feasible protocol; however, we should be aware of its effect on the intraprocedural anticoagulation and differences among DOACs in the responsiveness to heparin.

Highlights

Atrial fibrillation (AF) is a critical risk factor for cerebral thrombo‐ embolism and mortality.[1]
The dabigatran (231 ± 63 U/kg, P = .664) and edoxaban (239 ± 67 U/kg, P = .335) groups required total Unfractionated heparin (UFH) doses that were comparable with that required in the warfarin group (206 ± 53 U/kg), whereas the rivaroxaban (270 ± 63 U/kg, P < .001) and apixaban (263 ± 62 U/kg, P < .001) groups required significantly higher total UFH doses compared with the warfarin group
The current study found that minimally interrupted dabigatran was comparable to uninterrupted warfarin for intraprocedural an‐ ticoagulation based on the activated clotting time (ACT) transition pattern and target ACT > seconds (TTA) and re‐ quired the same dose of UFH

Summary

Introduction

Atrial fibrillation (AF) is a critical risk factor for cerebral thrombo‐ embolism and mortality.[1]. The improvement in thromboembolic complications has been owing to several factors, including continuation with vitamin K antagonists (VKAs) as a periprocedural anticoagulation protocol,[10] monitoring of activated clotting time (ACT) during the procedure,[11] and incorpora‐ tion of preprocedural transesophageal echocardiography and irriga‐ tion catheter ablation system. Methods: A total of consecutive 269 patients who undergone AF ablation were eli‐ gible for the study. All oral anticoagulants (OACs) were discontinued just one dose before the procedure except warfarin. We assessed the total required dose of UFH and time‐to‐target ACT > 300 seconds (TTA) for each of direct oral anticoagulant (DOAC) groups compared with the uninterrupted warfarin group. MID is a feasible protocol; we should be aware of its effect on the intraprocedural anticoagulation and differences among DOACs in the responsiveness to heparin

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Conclusion