Apixaban, rivaroxaban, and dabigatran use in patients undergoing catheter ablation for atrial fibrillation using the second‐generation cryoballoon

Abstract

Background Data are limited on the safety of periprocedural anticoagulation with novel oral anticoagulants (NOACs) in patients undergoing pulmonary vein isolation (PVI) using the second‐generation cryoballoon (CB) for the treatment of atrial fibrillation. Hypothesis We hypothesized that the incidence of acute periprocedural complications in patients undergoing PVI do not differ between patients treated with VKA compared to NOACs. Methods In 200 consecutive patients (mean age, 64.3 _ 10.6 years; female, n = 83) with symptomatic atrial fibrillation, PVI using the second‐generation 28‐mm CB was performed. In patients treated with NOACs, the medication was stopped the day of the procedure and continued the evening after the procedure with a reduced dosage. Patients treated with phenprocoumon were continued on uninterrupted phenprocoumon with a target INR of 2 to 3. If INR was <2, bridging with low‐molecular‐weight heparin was performed. Results Forty‐seven of 200 patients (23.5%) were treated with a vitamin K antagonist (VKA) and 55 (27.5%) were treated with apixaban, 67 (33.5%) with rivaroxaban, and 31 (15.5%) with dabigatran. Seven (3.5%) major complications occurred in the overall population. Major bleeding complications did not differ significantly between the 2 groups (P = 0.23). One patient taking VKA had a pericardial tamponade at the end of the procedure; 2 patients treated with apixaban developed a groin hematoma requiring surgical intervention. Transient ischemic attack occurred in 1 patient of the apixaban and rivaroxaban group. Conclusions Apixaban, rivaroxaban, and dabigatran, compared with uninterrupted VKA, did not show a higher risk for major bleeding or ischemic complications in patients undergoing PVI using the second‐generation CB.

Acute Procedural Complications of Cryoballoon Ablation: A Comprehensive Review

“…Despite high rate of silent cerebral embolic lesions, the incidence of TIA or stroke has been reported lower than 1% [108] . To decrease thromboembolic complications of ablation, uninterrupted anticoagulation strategy should be preferred compared with bridging strategies using heparin or enoxaparin regardles of used anticoagulant agent [109,110] . To reveal the presence of thrombus formation in the LAA, routine usage of transesophageal echocardiography is recommended by some authors.…”

Optimal interruption time of dabigatran oral administration to ablation (O-A time) in patients with atrial fibrillation: Integrated analysis of 2 randomized controlled clinical trials

“…With the advent of direct oral anticoagulants (DOACs), an increasing number of patients with AF undergo CA with DOAC ther-apy. Recent randomized clinical trials (RCTs) [5][6][7][8][9] , cohort studies [10][11][12] , and meta-analyses [13][14][15] have showed that uninterrupted or minimally interrupted DOACs are associated with lower or non-inferior risk of bleeding and thromboembolic events compared with uninterrupted warfarin. The 2017 consensus statement on AF ablation [1] recommends performing CA without anticoagulant interruption with warfarin or dabigatran (class I); however, it also stated that holding 1 to 2 doses of DOAC prior to CA is reasonable (class IIa).…”

Periprocedural management of anticoagulation for atrial fibrillation catheter ablation in direct oral anticoagulant–treated patients

“…Although a few recent studies report that uninterrupted DOAC therapy during AF ablation is feasible and safe, the critical point of intraprocedural anticoagulation management has not been addressed and protocols on UFH administration and ACT monitoring are lacking. [6][7][8][9] However, several arguments support that UFH management cannot be directly extrapolated from VKA-treated patients: the initial level of anticoagulation varies according to DOAC concentration, DOAC interferes with the ACT, and the sensitivity of the ACT to DOAC as well as the response to UFH administration in DOAC-treated patients strongly differ from that of VKA-treated patients and also among DOACs. 10,11 This study aims to illustrate intraprocedural UFH management complexity in uninterrupted DOAC-treated patients.…”

“…In uninterrupted DOAC–treated patients, the same ACT ≥300 seconds usually proposed for intraprocedural UFH is based on very limited evidence, mostly extrapolated from VKA‐treated populations. Although a few recent studies report that uninterrupted DOAC therapy during AF ablation is feasible and safe, the critical point of intraprocedural anticoagulation management has not been addressed and protocols on UFH administration and ACT monitoring are lacking . However, several arguments support that UFH management cannot be directly extrapolated from VKA‐treated patients: the initial level of anticoagulation varies according to DOAC concentration, DOAC interferes with the ACT, and the sensitivity of the ACT to DOAC as well as the response to UFH administration in DOAC‐treated patients strongly differ from that of VKA‐treated patients and also among DOACs …”

“…The consequences of this mismanagement are unclear. The recent studies assessing AF catheter ablation with uninterrupted DOAC reported a low incidence of bleeding and thromboembolic events, similar to uninterrupted VKA, but UFH management remained unknown [7][8][9]. One could argue that the potential UFH overdose induced by DOAC-ACT and UFH-DOAC interference is not relevant, as major bleeding events occur infrequently, nevertheless, blinded intraprocedural anticoagulation may make it harder to manage complications.Although our study is not designed to modify clinical practice, it aims to draw attention to an unknown and neglected aspect of AF catheter ablation.…”