Outcomes of uninterrupted vs interrupted Periprocedural direct oral Anticoagulants in atrial Fibrillation ablation: A meta-analysis.

Indranill Basu-Ray,Sumit K Shah,Sue A Theus,Jared Bunch,Dibbendhu Khanra,Anindya Mukherjee,Péter Kupó,John Jefferies,András Komócsi,Adedayo Adeboye

doi:10.1002/joa3.12507

Abstract

BackgroundStudies indicate that uninterrupted anticoagulation (UA) is superior to interrupted anticoagulation (IA) in the periprocedural period during catheter ablation of atrial fibrillation. Still IA is followed in many centers considering the bleeding risk. This meta‐analysis compares interrupted and uninterrupted direct oral anticoagulation during catheter ablation of atrial fibrillation.MethodsA systematic search into PubMed, EMBASE, and the Cochrane databases was performed and five studies were selected that directly compared IA vs UA before ablation and reported procedural outcomes, embolic, and bleeding events. The primary outcome of the study was major adverse cerebro‐cardiovascular events.ResultsThe meta‐analysis included 840 patients with UA and 938 patients with IA. Median follow‐up was 30 days. Activated clotting time (ACT) before first heparin bolus was significantly longer with UA (P = .006), whereas mean ACT was similar between the two groups (P = .19). Total heparin dose needed was significantly higher with IA (mean, ‒1.61; 95% CI, ‒2.67 to ‒0.55; P = .003). Mean procedure time did not vary between groups (P = .81). Overall complication rates were low, with similar major adverse cerebro‐cardiovascular event (P = .40) and total bleeding (P = .55) rates between groups. Silent cerebral events (SCEs) were significantly more frequent with IA (log odds ratio, ‒0.90; 95% CI, ‒1.59 to ‒0.22; P < .01; I 2, 33%). Rates of major bleeding, minor bleeding, pericardial effusion, cardiac tamponade, and puncture complications were similar between groups.ConclusionsUA during atrial fibrillation ablation has similar bleeding event rates, procedural times, and mean ACTs as IA, with fewer SCEs.

Highlights

Catheter ablation of atrial fibrillation (AF) has expanded enormously over recent years, given improvements in available hardware, newer technologies, and growing evidence that the procedure is effective for rhythm control in patients with AF.[1]
Activated clotting time before first heparin bolus was significantly longer with uninterrupted anticoagulation (P=.006), whereas mean activated clotting time was similar between the 2 groups (P=.19)
Total heparin dose needed was significantly higher with interrupted anticoagulation

Summary

Introduction

Catheter ablation of atrial fibrillation (AF) has expanded enormously over recent years, given improvements in available hardware, newer technologies, and growing evidence that the procedure is effective for rhythm control in patients with AF.[1]. Direct oral anticoagulants (DOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban, have largely replaced the vitamin K antagonist warfarin in recent years, as they are associated with lower risk for bleeding events and better stroke prevention in patients with AF.[4] Even so, many operators believe it wise to allow a 24-hour gap in the DOAC regimen before catheter ablation of AF to avoid bleeding risks, despite the fact that guidelines recommend uninterrupted DOAC administration in the periprocedural period[57] and that studies have shown better results from uninterrupted versus interrupted anticoagulation regimens, with better prevention of embolic events.[8] Studies addressing the safety and efficacy of an interrupted DOAC regimen during catheter ablation of AF are few and are limited by small sample sizes, short follow-up periods, rare events, and variable outcomes. The purpose of this metaanalysis was to compare interrupted and uninterrupted direct oral anticoagulation during catheter ablation of atrial fibrillation

Methods

Results

Conclusion