Effect of Therapeutic INR on Activated Clotting Times, Heparin Dosage, and Bleeding Risk During Ablation of Atrial Fibrillation

Atrial fibrillation is the most common sustained arrhythmia in clinical practice, associated with increased mortality, risk of stroke and heart failure, as well as the reduction of the quality of life. Atrial fibrillation may be encountered in young otherwise healthy individuals, due to the isolated electrophysiological disorder limited mostly to the pulmonary veins and posterior left atrial wall, or associated with the presence of advanced underlying heart disease and numerous cardiac and non-cardiac comorbidities with significant structural remodeling of the atrial myocardium. Due to limited efficacy and serious side effects of antiarrhythmic drugs, catheter ablation of atrial fibrillation, based on the pulmonary vein isolation for paroxysmal atrial fibrillation and adjunctive substrate modification for persistent atrial fibrillation, has emerged as an attractive and promissing alternative therapeutic option for selected patients with atrial fibrillation. In this review article, we discuss the electrophysiological left atrial abnormalities underlying lone atrial fibrillation and the role of pulmonary veins in pathophysiology of arrhythmia, and we summarize results of the studies on the long term outcome of catheter ablation of atrial fibrillation, as well as the studies on comparison of antiarrhythmic drugs with catheter ablation for treatment of atrial fibrillation. In addition, we present available data that provide better understanding of mechanisms, diagnosis, prevention and treatment of specific procedure-related complications and discuss current periprocedural anticoagulation strategies and their impact on the thromboembolic risk reduction.

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“…Catheter ablation of AF under therapeutic INR is simple and requires smaller dose of intravenous heparin during the procedure [165].…”

Section: Thromboembolic Complications Preprocedural Thrombosis Tranmentioning

confidence: 99%

Catheter Ablation of Lone Atrial Fibrillation

Mujović

Marinković²,

Potpara³

et al. 2014

CPD

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“…In conducting ablation with ongoing warfarin, INR levels should be kept in the therapeutic range because a lower level of INR necessitates a larger amount of heparin during the procedure, which might lead to a higher risk of both bleeding and thrombosis. 16 …”

Section: Main Findingsmentioning

confidence: 99%

“…Several recent studies have shown that continued use of warfarin in the periprocedural period with therapeutic international normalized ratio (INR) is effective or better in preventing thromboembolic events in AF ablation procedures. 12- 16 The focus of these studies was incidence of thromboembolic events when warfarin was continued, compared to bridging with heparin and analogs, and did not assess whether continued warfarin resulted in an increased number of bleeding complications (BC) at the expense of fewer embolic events. We hypothesized that BC could increase with periprocedural therapeutic INR.…”

mentioning

confidence: 99%

Preprocedural Therapeutic International Normalized Ratio Influence on Bleeding Complications in Atrial Fibrillation Ablation With Continued Anticoagulation With Warfarin

Hayashi

Kumagai

Naito

et al. 2013

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp atheter ablation aimed at curing atrial fibrillation (AF) has become increasingly common, and its efficacy is established. 1-3 Although the procedure is generally effective and safe, 4,5 serious complications occasionally do occur, including death. 6,7 The overall peri-procedural risk of thromboembolic events has been reported to be approximately 1.6-2.2% in focal AF ablations, 4,8-10 and as high as 7% in linear AF ablations. 11 Nevertheless, it has been common practice to interrupt warfarin before AF ablation procedures and use bridging with heparin or enoxaparin instead. Several recent studies have shown that continued use of warfarin in the periprocedural period with therapeutic international normalized ratio (INR) is effective or better in preventing thromboembolic events in AF ablation procedures. 12-16 The focus of these studies was incidence of thromboembolic events when warfarin was continued, compared to bridging with heparin and analogs, and did not assess whether continued warfarin resulted in an increased number of bleeding complications (BC) at the expense of fewer embolic events. We hypothesized that BC could increase with periprocedural therapeutic INR. Administration of heparin in combination with warfarin is believed to provide a stronger anticoagulant effect, but optimal dose and timing of heparin administration is unknown. Therefore, the purpose of the current study was to assess the safety of AF ablation in conditions of peri-procedural therapeutic INR in combination with heparin, and to investigate the risk factors for BC when this method was used.

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“…In a study at the Brigham and Women's Hospital, we observed a 0.7% incidence of stroke or transient ischemic attack. 6 It is important to recognize that the incidence of asymptomatic embolic events may be much higher. In this issue of Circulation, Gaita et al 7 report a 0.4% incidence of clinically apparent stroke and a 14% incidence of silent cerebral embolism in 234 consecutive patients studied by cranial MRI the day after the ablation procedure.…”

Section: Article See P 1667mentioning

confidence: 99%