Abstract
Background. Cerebral thromboembolism is a rare but feared complication of transcatheter ablation in patients with atrial fibrillation (AF). Here, we aimed to test which pre-procedural anticoagulation strategy results in less intracardiac activation of hemostasis during ablation. Patients and methods. In this observational study, 54 paroxysmal/persistent AF patients undergoing cryoballoon ablation were grouped according to their periprocedural anticoagulation strategy: no anticoagulation (oral anticoagulation (OAC) free; n = 24), uninterrupted vitamin K antagonists (VKA) (n = 11), uninterrupted dabigatran (n = 17). Blood was drawn from the left atrium before and immediately after the ablation procedure. Cryoablations were performed according to standard protocols, during which heparin was administered. Heparin-insensitive markers of hemostasis and endothelial damage were tested from intracardiac samples: D-dimer, quantitative fibrin monomer (FM), plasmin-antiplasmin complex (PAP), von Willebrand factor (VWF) antigen, chromogenic factor VIII (FVIII) activity. Results. D-dimer increased significantly in all groups post-ablation, with lowest levels in the dabigatran group (median [interquartile range]: 0.27 [0.36] vs. 1.09 [1.30] and 0.74 [0.26] mg/L in OAC free and uninterrupted VKA groups, respectively, p < 0.001). PAP levels were parallel to this observation. Post-ablation FM levels were elevated in OAC free (26.34 [30.04] mg/L) and VKA groups (10.12 [16.01] mg/L), but remained below cut-off in all patients on dabigatran (3.98 [2.0] mg/L; p < 0.001). VWF antigen and FVIII activity increased similarly post-ablation in all groups, suggesting comparable procedure-related endothelial damage. Conclusion. Dabigatran provides greater inhibition against intracardiac activation of hemostasis as compared to VKAs during cryoballoon catheter ablation.
Highlights
Transcatheter isolation of pulmonary veins (PVI) is an established therapy for atrial fibrillation (AF) [1]
While the use of non-fractionated heparin to reach a target activated clotting time (ACT) of 300 s or above during catheter dwelling in left atrial (LA) is a standard practice, optimal oral anticoagulation (OAC) before the ablation has been a matter of long-term debate
The comprehensive evaluation of our results suggests that dabigatran has the strongest potential to prevent the hypercoagulable state related to a left atrial ablation procedure, while patients undergoing AF ablation with effective vitamin K antagonists (VKA) anticoagulation might still be exposed to significant hemostasis activation
Summary
Transcatheter isolation of pulmonary veins (PVI) is an established therapy for atrial fibrillation (AF) [1]. The risk of a potentially life-threatening bleeding complication inherent to transseptal catheterization, catheter manipulation, and the delivery of ablative energy in the thin-wall LA argue against uninterrupted administration of any OAC in the absence of a specific antidote capable of restoring hemostasis in case of a bleeding complication. Despite these concerns, observational and randomized clinical trials have demonstrated the safety or even superiority of uninterrupted administration of vitamin K antagonists (VKA) [9,10,11]. Three different peri-procedural antithrombotic treatment schemes were compared: 1, no pre-ablation OAC administration; 2, uninterrupted VKA administration, and 3, uninterrupted dabigatran administration
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