Uninterrupted Strategy Research Articles

Interrupted versus uninterrupted anticoagulation therapy for catheter ablation in adults with arrhythmias.

Interrupted versus uninterrupted anticoagulation therapy for catheter ablation in adults with arrhythmias.

Real-world comparison of different periprocedural antithrombotic strategies for atrial fibrillation catheter ablation

Abstract Introduction Atrial Fibrillation (AF) catheter ablation carries high bleeding and thromboembolic risks, requiring a detailed assessment of overall risk-benefit profile regarding antithrombotic strategy. Vitamin K Anticoagulant (VKA) and Non-Vitamin K Antagonist Oral Anticoagulant (NOAC) have been used in the latest years in this setting, and with different interruption protocols periprocedural. Our goal was to evaluate the rate of acute adverse events (AAE) and compare them according to antithrombotic strategy used periprocedural, in a real-world basis. Methods A single-center retrospective study, including adult patients admitted to first AF catheter ablation, from 2004 to 2020. Different antithrombotic strategies (anticoagulation with VKA uninterrupted, anticoagulation with NOAC uninterrupted, no therapy or antiaggregation/interrupted ACO) were compared concerning the rate of any clinically relevant AAE; the composite of major AAE (hemopericardium and stroke/transient ischemic attack [TIA]) and minor AAE associated with vascular access. Descriptive statistics and logistic regression were used to compare groups according to the antithrombotic strategy with an alpha level of 0.05. Results Among the 868 patients included (mean age 59±12 yo, 67,5% [n=586] men), pulmonary vein isolation was performed under uninterrupted anticoagulation in 640 (73,7%), of which 595 patients with NOAC (68,5%) and 45 with VKA (5,2%). AF was paroxysmal, persistent and long-standing persistent in 63,4% (n=550), 21,4% (n=185) and 15,4% (n=133) patients, respectively. Mean CHADS-VASc score was 1,86±1,48. Over time there was a shift in the distribution of the type of antithrombotic therapy used, consistent with changes in recommendations (Graph 1). The composite outcome occurred in 6,8% (n=62), including hemopericardium in 1,8% (n=16), stroke/TIA in 0,7% (n=6) and events related to vascular access in 1,4% (n=13) [Table 1]. No anticoagulation therapy or antiaggregation/interrupted ACO was more associated to the outcome, driven by major AAE, although the difference did not meet statistical significance (p=0,06) [Table 1]. No difference was found between VKA and NOAC group. Additionally, there was no diference in the incidence of hemorrhagic AAE since the implementation of an uninterrupted anticoagulation strategy periprocedural. Conclusion In our population of patients submitted to AF catheter ablation, an uninterrupted anticoagulation strategy is associated with lower rate of AAE, either with VKA or NOAC. Our real-world results are reassuring of the benefit of an uninterrupted strategy, and consistent with recent controlled trials. Funding Acknowledgement Type of funding sources: None. Antithrombotic therapies over timeClinically relevant acute adverse events

Influence of oral anticoagulants on activated clotting time (ACT) during catheter ablation of atrial fibrillation

Catheter ablation has gained a prominent role in the management of atrial fibrillation (AF), with recent data providing positive evidence on hard outcomes. Ablation, however, exposes the patient to risks for both major bleeding and thromboembolic events. 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 (UFH) adjusted to achieve and maintain a target ACT of ≥ 300 seconds. Observational studies and randomized controlled trials support the safety and efficacy of uninterrupted NOAC strategy for AF catheter ablation, however heparin doses are not the same for all uninterrupted strategies. The aim of this study is to establish a correlation between ACT and UFH concentration for each oral anticoagulants. We proved with a retrospective study that heparin doses are almost twice superior for patients under direct oral anticoagulants than vitamin K antagonist (VKA) to achieve the target ACT ≥ 300 seconds during AF ablation. A prospective study includes uninterrupted patients requiring AF ablation. Preprocedural NOACs concentration, intraprocedural UFH administration, ACT values and UFH concentration are recorded for each group of direct oral anticoagulant including rivaroxaban, apixaban, dabigatran and for VKA group. One hundred and twenty patients (thirty in each anticoagulant group) underwent AF are included for atrial catheter ablation. We study correlation between ACT and UFH concentration for each group. This study explores the physiology of anticoagulation during AF catheter ablation and the relevant differences between VKA and NOACs. ACT is not specific to UFH, multiple interferences between DOAC, UFH, and ACT question the reliability of this monitoring.

Thromboembolism and bleeding risk in atrial fibrillation ablation with uninterrupted anticoagulation between new oral anticoagulants and vitamin K antagonists: insights from an updated meta-analysis.

Cumulative reports comparing the efficacy and safety outcomes between uninterrupted NOACs and vitamin K antagonists (VKA) in AF ablation had been freshly published. This meta-analysis aimed at offering a more comprehensive evaluation between these two anticoagulants in uninterrupted strategy. We searched in PUBMED, EMBASE, and Cochrane Library (inception to June 10, 2019) for eligible studies. Fixed-effects model was preferred in pooled analysis if I2 < 50%. Publication bias was also evaluated. A total of 23 studies involving 12,725 individuals were analyzed in this literature. There were no difference between uninterrupted NOACs and VKA groups in incidence of Stroke/TIA (RR 0.98, 95% CI 0.54-1.77, P = 0.93, I2 = 0%), silent cerebral embolism (RR 1.09, 95% CI 0.82-1.43, P = 0.56, I2 = 0%), minor bleeding complication (RR 0.97, 95% CI 0.83-1.14, P = 0.73, I2 = 0%), cardiac tamponade (RR 0.95, 95% CI 0.63-1.42, P = 0.80, I2 = 0%). Uninterrupted NOACs was associated with significantly lower major bleeding incidence (RR 0.67, 95% CI 0.49-0.92, P = 0.01, I2 = 0%), pericardial effusion (RR 0.75, 95% CI 0.56-1.00, P = 0.048, I2 = 9%). In sub-analysis, no difference was found in all sub-analyses for Stroke/TIA while significant major bleeding risk reduction in uninterrupted NOACs was identified in the subgroup of CHA2DS2-VASc score ≥ 2 and target activated clotting time (ACT) > 300 s. In conclusions, uninterrupted NOACs was more effective than uninterrupted VKA in reducing major bleeding and pericardial effusion risk without increasing thromboembolism risk, and the benefits of uninterrupted NOACs on major bleeding complication could be more pronounced if CHA2DS2-VASc score ≥ 2 or target ACT > 300 s.

Uninterrupted non-vitamin K antagonist oral anticoagulants during implantation of cardiac implantable electronic devices in patients with atrial fibrillation.

For patients with atrial fibrillation (AF) receiving cardiac implantable electronic device (CIED) implantations, current consensus recommends uninterrupted non-vitamin K antagonist oral anticoagulant (NOAC) considering low incidence of bleeding or thrombo-embolic events. It remains unknown whether uninterrupted strategy outweighs discontinuation method for patients receiving NOAC. From January 1, 2013 to June 1, 2017, we enrolled 100 patients (mean age 78.3 ± 10.2 years, 58% male) with AF taking NOAC for stroke prevention eligible for CIED implantation in a tertiary medical center, Taipei, Taiwan. NOAC was continued without skipping any doses during the surgery. The baseline characteristics, underlying diseases, CHA2DS2-VASc score, and clinical course of every patient were reviewed and analyzed. Among these patients, 28 were on dabigatran, 61 on rivaroxaban, 10 on apixaban, and one on edoxaban, respectively. There were no adverse events except one case of pericardial effusion and another one with large pocket hematoma. One patient receiving implantable cardioverter defibrillator implantation had late onset of pericardial effusion with impending tamponade necessitating pericardiocentesis. Another patient had large pocket hematoma, which spontaneously resolved within 1 month without further intervention. No periprocedural mortality and stroke occurred. Uninterrupted NOAC during CIED implantations may be an acceptable option especially in patients with high risk for thromboembolism. However, special caution should be paid during defibrillator implantation considering relatively higher risk of bleeding, perhaps due to the larger size of the defibrillator lead.

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

Periprocedural anticoagulation is important in catheter ablation (CA) of atrial fibrillation (AF) and there is increasing evidence that uninterrupted vitamin K antagonist (VKA) therapy is superior to interrupted anticoagulation strategies. Since the emergence of direct oral anticoagulants (DOACs), numerous studies have shown promising results for their use in uninterrupted strategies. However, further studies are needed to further define the efficacy and safety of performing AF ablation with uninterrupted factor XA inhibitors or direct thrombin inhibitors.Methods and Results:We have performed CA of AF without discontinuation of either VKA or DOAC therapy since April 2014. A total of 376 patients with AF underwent CA including pulmonary vein isolation. All of the patients were divided into 2 groups (uninterrupted VKA or uninterrupted DOACs). Anticoagulation with DOACs was associated with fewer complications than uninterrupted VKA therapy (P=0.04). There were significant differences between groups in the rates of congestive heart failure, left ventricular ejection fraction, body weight, and estimated glomerular filtration rate and of the CHADS2, CHA2DS2-VASc and HAS-BLED scores. Therefore, we also analyzed the results using the propensity score-matching method. We found no significant difference in periprocedural complications between uninterrupted VKA or DOACs therapy (P=0.65). CA of AF without discontinuation of DOACs is not inferior to CA without discontinuation of a VKA, with regard to ischemic or hemorrhagic complications.

Abstract 16402: Feasibility and Safety of Uninterrupted Rivaroxaban in Patients Undergoing Radiofrequency Ablation for Long Standing Persistent Atrial Fibrillation

Introduction: Periprocedural anticoagulation management is key to minimize bleeding and thromboembolic complications during and after radiofrequency catheter ablation. Uninterrupted strategies with warfarin in high risk patients have shown superiority over interrupted strategies. We sought to assess the safety and feasibility uninterrupted rivaroxaban during atrial fibrillation (AF) ablation in patients with long standing persistent atrial fibrillation. Methods: One hundred and ninety six (196) consecutive patients undergoing AF ablation with uninterrupted rivaroxaban (last dose taken with food the night before the procedure and the following dose taken the night of the procedure) were matched by age and sex with an equal number of patients undergoing AF ablation with uninterrupted warfarin on a “therapeutic range”. All patients underwent pulmonary vein antrum isolation and ablation of non pulmonary vein triggers as disclosed by isoproterenol challenge test. Results: Baseline characteristics and procedural variables were similar between groups. Mean INR in warfarin group was 2.2 ± 0.5. CHADS2 Score was ≥ 2 in 141 (72%) in the rivaroxaban group and 130 (66%) in the warfarin patients (p=0.20). One pericardial tamponade and one groin hematoma occurred in rivaroxaban group while 2 patients in warfarin group developed groin hematoma. One TIA with positive MRI was present in the rivaroxaban group. Conclusions: Uninterrupted rivaroxaban therapy appears to be as safe and efficacious as uninterrupted warfarin strategy in preventing bleeding and thromboembolic events in patients undergoing long standing persistent AF ablation.