Anticoagulation use and clinical outcomes after catheter ablation in patients with persistent and longstanding persistent atrial fibrillation

Liang, Jackson J.; Elafros, Melissa A.; Mullen, Michael T.; Muser, Daniele; Hayashi, Tatsuya; Enríquez, Andrés; Pathak, Rajeev K.; Zado, Erica S.; Arkles, Jeffrey; Schaller, Robert D.; Supple, Gregory E.; Frankel, David S.; García, Fermin C.; Deo, Rajat; Lin, David; Riley, Michael P.; Nazarian, Saman; Marchlinski, Francis E.; Callans, David J.

doi:10.1111/jce.13476

Cited by 22 publications

(33 citation statements)

References 45 publications

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“…In the study by Liang et al., it was reported that 7 patients experienced thromboembolic stroke, 4 in patients who were on therapeutic anticoagulation. It is not clear to the reader why these patients had stroke during therapeutic AC.…”

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confidence: 82%

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Is it safe to stop oral anticoagulation after catheter ablation of atrial fibrillation?

Romero

Biase

2018

Cardiovasc electrophysiol

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The percentage of strokes attributable to atrial fibrillation (AF) increases steeply from 1.5% at 50-59 years to 23.5% at 80-89 years. 1 Additionally, the prevalence of AF and the associated risk of ischemic stroke might be substantially underestimated given that AF is frequently asymptomatic and undiagnosed particularly after ablation of AF. 2 This assumption has been validated by a study in which subclinical atrial tachyarrhythmias without clinical AF occurred frequently in patients with pacemakers and were associated with a significantly increased risk of ischemic stroke or systemic embolism. 3 A recent large propensity score matching study has shown that catheter ablation of AF is associated with a 31% lower risk of thromboembolic stroke predominantly among patients with high CHADS 2 VAS 2 score (i.e., > 2) and among patients without AF recurrences. 4 Nevertheless, although elimination of AF or reduction of AF burden by catheter ablation may result in a significant reduction in stroke risk, whether to stop oral anticoagulation (OA) after these procedures is currently a topic of great controversy. Liang et al. 5 in this issue of Journal of Cardiovascular Electrophysiology, evaluated whether OAC therapy can be safely discontinued in patients rendered free of AF recurrences and examined long-term rates of stroke and major bleeding episodes in patients with nonparoxysmal AF treated with catheter ablation. A total of 400 patients with nonparoxysmal AF (200 persistent, 200 longstanding persistent) who underwent their first AF ablation were included in this analysis. These patients were followed for 3.6 ± 2.4 years. At the end of follow-up, 172 (43.0%) patients were free of AF recurrence. Patients without AF recurrence were more likely to discontinue OAC. Patients with persistent versus longstanding persistent AF type prior to ablation and those with CHA2DS2-VASc score < 2 were less likely to continue OAC. A total of 7 patients had cerebrovascular accidents (incidence: 0.49/100 patient/years) and 14 experienced major bleeding during follow-up (incidence: 0.98/100 patient/years). The authors concluded that AC Dr. Di Biase is a consultant for Biosense Webster, Stereotaxis, Boston Scientific, and Abbott, and has received speaker honoraria/travel from Medtronic, Pfizer, and Biotronik. Dr. Romero has no disclosures. discontinuation in well selected, closely monitored patients following successful ablation of nonparoxysmal AF is associated with a low rate of clinical stroke.The latest 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of AF advises that decisions regarding continuation of systemic anticoagulation after the blanking period (i.e., 2-3 months) should be based primarily on a patient's CHA2DS2-VASc score and not on the apparent success or failure of the ablation procedure. 6 This recommendation is based primarily on the fact that there are only a few observational and retrospective studies on this topic but more importantly because these studies have shown contradict...

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supporting

confidence: 82%

“…Liang et al . in this issue of Journal of Cardiovascular Electrophysiology , evaluated whether OAC therapy can be safely discontinued in patients rendered free of AF recurrences and examined long‐term rates of stroke and major bleeding episodes in patients with nonparoxysmal AF treated with catheter ablation.…”

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confidence: 99%

Is it safe to stop oral anticoagulation after catheter ablation of atrial fibrillation?

Romero

Biase

2018

Cardiovasc electrophysiol

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“…Some studies in our analysis included several patients with mechanical heart valves, which precluded the discontinuation of OAC, a fact that was confirmed by contacting the corresponding authors. The paper by Gallo et al was the only that excluded patients with mechanical heart valves from its analysis.…”

Section: Limitationsmentioning

confidence: 85%

“…Hunter et al used a multicenter registry in the UK and Australia. Liang et al used data collected in the University of Pennsylvania. Gallo et al retrospectively analyzed data from three Italian registries: Cardinal Massaia Hospital of Asti, Mauriziano Hospital of Turin and Città della Salute e della Scienza Hospital of Turin.…”

Section: Resultsmentioning

confidence: 99%

Oral anticoagulation after catheter ablation of atrial fibrillation and the associated risk of thromboembolic events and intracranial hemorrhage: A systematic review and meta‐analysis

Romero

Cerrud‐Rodriguez

Díaz

et al. 2019

Cardiovasc electrophysiol

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Aims: We sought to examine whether continuing oral anticoagulation (OAC) after catheter ablation (CA) for atrial fibrillation (AF) is associated with improved outcomes. OAC reduces morbidity and mortality in patients with AF. However, the continuation of OAC following the blanking period of CA is controversial due to conflicting published data.Methods: A systematic review of Medline, Cochrane, and Embase was performed for studies comparing patients who were continued on OAC (ON-OAC) vs those in which OAC was discontinued (OFF-OAC). CHA 2 DS 2 VASc score had to be available for the classification of patients into high-or low-risk cohorts (CHA 2 DS 2 VASc ≥ 2 and ≤ 1, respectively). The primary efficacy outcome was thromboembolic events (TE). Intracranial hemorrhage (ICH) was the primary safety outcome.Results: Five studies comprising 3956 patients were included (mean age, 61.1 ± 2.9 years; 72.4% male, CHA 2 DS 2 VASc ≤ 1 50.1%; CHA 2 DS 2 VASc ≥ 2 49.9%). After a mean follow-up of 39.6 ± 11.7 months, OAC-continuation was associated with a significant decrease in risk of TE in the high-risk cohort (CHA 2 DS 2 VASc ≥ 2) (risk ratio [RR] 0.41, 95% confidence interval [CI] 0.21-0.82, P = .01) with a RR reduction of 59%. ICH was significantly higher in the ON-OAC group (RR, 5.78; 95% CI, 1.33-25.08; P = .02). No significant benefit was observed in the low-risk cohort ON-OAC after the blanking period. Conclusion: Continuation of OAC after CA of AF with CHA 2 DS 2 VASc ≥ 2 is associated with a significant decreased TE risk and a favorable net clinical benefit in Jorge Romero, MD and Roberto C. Cerrud-Rodriguez, MD contributed equally to this work. How to cite this article: Romero J, Cerrud-Rodriguez RC, Diaz JC, et al. Oral anticoagulation after catheter ablation of atrial fibrillation and the associated risk of thromboembolic events and intracranial hemorrhage: A systematic review and meta-analysis.

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“…In the study by Liang et al, 5 it was reported that 7 patients experienced thromboembolic stroke, 4 in patients who were on therapeutic anticoagulation. It is not clear to the reader why these patients had stroke during therapeutic AC.…”

mentioning

confidence: 99%

Is it safe to stop oral anticoagulation after catheter ablation for atrial fibrillation?

Romero

Avendaño

Díaz

et al. 2018

Expert Review of Cardiovascular Therapy

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Anticoagulation use and clinical outcomes after catheter ablation in patients with persistent and longstanding persistent atrial fibrillation

Abstract: Anticoagulation discontinuation in well selected, closely monitored patients following successful ablation of nonparoxysmal AF was associated with a low rate of clinical embolic CVEs. Prospective studies are required to confirm safety of OAT discontinuation after successful AF ablation.

Cited by 22 publications

References 45 publications

Is it safe to stop oral anticoagulation after catheter ablation of atrial fibrillation?

Is it safe to stop oral anticoagulation after catheter ablation of atrial fibrillation?

Oral anticoagulation after catheter ablation of atrial fibrillation and the associated risk of thromboembolic events and intracranial hemorrhage: A systematic review and meta‐analysis

Is it safe to stop oral anticoagulation after catheter ablation for atrial fibrillation?

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