Factors associated with silent cerebral events during atrial fibrillation ablation in patients on uninterrupted oral anticoagulation

Abstract

Introduction Silent cerebral events (SCEs) are related to the potential thromboembolic risk in atrial fibrillation (AF) ablation. Periprocedural uninterrupted oral anticoagulation (OAC) reportedly reduced the risk of SCEs, but the incidence still remains. Methods and Results AF patients undergoing catheter ablation were eligible. All patients took non–vitamin K antagonist oral anticoagulants (NOACs; n = 248) or vitamin K antagonist (VKA; n = 37) for periprocedural OAC (>4 weeks) without interruption during the procedure. Brain magnetic resonance imaging was performed within 2 days after the procedure to detect SCEs. Clinical characteristics and procedure‐related parameters were compared between patients with and without SCEs. SCEs were detected in 66 patients (23.1%; SCE[+]) but were not detected in 219 patients (SCE[−]). Age was higher in SCE[+] than in SCE[−] (66 ± 10 vs. 62 ± 12 years; p < .05). Persistent AF prevalence, CHADS2/CHA2DS2‐VASc scores, serum NT‐ProBNP levels, left atrial dimension (LAD), and spontaneous echo contrast prevalence in transesophageal echocardiography significantly increased in SCE[+] versus SCE[−]. SCE[+] had lower baseline activated clotting time (ACT) before heparin injection and longer time to reach optimal ACT (>300 s) than SCE[−] (146 ± 27 vs. 156 ± 29 s and 44 ± 30 vs. 35 ± 25 min; p < .05, respectively). In multivariate analysis, age, LAD, baseline ACT, and time to reach the optimal ACT were predictors for SCEs. The average values of the ACT parameters were significantly different among NOACs/VKA. Conclusion Age, LAD, and intraprocedural ACT kinetics significantly affect SCEs during AF ablation. Different anticoagulants have different impacts on ACT during the procedure, which should be considered when estimating the risk of SCEs.

Improved left atrial appendage closure procedural efficiency using radiofrequency transseptal wire system

“…While implant recapture to adjust position after deployment is not typically a lengthy process, the decision to proceed with this step may require significant consultation and additional imaging, which, if required, can substantially prolong the procedure time. This observation supports the hypothesis that optimized coaxiality and assessment of LAA size can support more efficient and effective LAAC, thereby reducing safety risks that may be associated with excess device and catheter manipulations 13,15,16 . While other dedicated RF transseptal puncture technologies have been shown to be effective, 11,14 to our knowledge this is the only study where a RF wire‐based system improved LAAC procedural efficiency in addition to a more favorable transseptal time.…”

Different Kinetics of Activated Clotting Time Among Uninterrupted Oral Anticoagulants During Catheter Ablation Procedure

“…Nagao et al 13 demonstrated the average time required for achieving a target ACT >300 seconds was significantly longer in the dabigatran and apixaban groups than in the warfarin and rivaroxaban groups, although these findings are discrepant to the present study results. In accordance with our findings, Harada et al 14 showed a longer time to reach ACT >300 seconds in the rivaroxaban and apixaban groups than the dabigatran, edoxaban, and warfarin groups. In the present study, furthermore, we first addressed the different stabilities using ACT‐TTR during the ablation procedure according to OAC.…”

“…Regarding silent cerebral events, Nagao et al 19 reported a significantly higher incidence of silent stroke during the ablation procedure in the dabigatran group than in the other DOACs under uninterrupted use. Meanwhile, Harada et al 14 reported that silent cerebral events during the procedure were associated with higher age, larger left atrial dimension, lower baseline ACT, and longer time to reach optimal ACT in multivariate analysis, but the event rate was not different according to OAC groups. Silent cerebral events also depend on types of ablation devices and procedure time, and bleeding complications greatly depend on operator skills 20–22 .…”

“…Activated clotting time (ACT) is monitored as an index for blood coagulability and recommended targeting between 300 and 400 seconds during an ablation procedure to reduce periprocedural thromboembolic events and bleeding events, 1,10,11 while the kinetics of ACT with heparin are different according to respective OACs, as reported in several studies. [12][13][14] However, the ACT kinetics, including stability, have not been fully evaluated among all OACs.…”

Real-World Investigation on Anticoagulation Management Before and After Catheter Ablation for Atrial Fibrillation in Japan ― Periprocedural and Long-Term Outcomes ―

“…Several studies have indicated that dabigatran is more sensitive to activated clotting time (ACT) assays compared with other DOACs. [35][36][37] The Remote Period After CA The RYOUMA registry also provides valuable data on the continuation of OAC and outcomes during the remote period after CA. At 1 year after CA, DOAC therapy was continued in 55.9% of patients and warfarin therapy in 56.4% of patients.…”