Peri-procedural anticoagulation in patients undergoing ablation for atrial fibrillation

Abstract

Radiofrequency catheter ablation is being used with increasing frequency as a strategy to manage atrial fibrillation. Patients undergoing this procedure are at increased short-term risk of thromboembolism for several days and up to 4 weeks or longer after their ablation, and anticoagulation management surrounding the ablation procedure remains controversial. Although no conclusive recommendations can be made, published guidelines and data support therapeutic anticoagulation with warfarin for 3 weeks prior and intravenous heparin during the ablation. Warfarin may either be continued through the ablation or stopped 2–5 days prior. If the latter approach is chosen, a pre-ablation bridging strategy of enoxaparin 1 mg/kg twice daily is reasonable in selected patients unless the patient’s bleeding risk dictates using a lower dose regimen (0.5 mg/kg twice daily) or avoiding bridging altogether. Fewer data are available for post-ablation management strategies, and current practice patterns are based largely on single-center experiences in smaller, non-randomized studies. For lower risk patients (CHADS2 0–1), either warfarin or aspirin may be utilized without bridging. In higher thromboembolic risk patients (CHADS2 ≥ 2), either enoxaparin (1 mg/kg twice daily) or heparin may be started within the first 12–24 h post-procedure. For patients with bleeding risk factors, enoxaparin may be subsequently reduced to 0.5 mg/kg until the INR is therapeutic, although the efficacy of this lower dosing regimen has not been well studied. In accordance with national guidelines, warfarin should be continued post-ablation for a minimum of 2 months and then indefinitely in patients with a CHADS2 score ≥ 2.

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…796,797,798,799 ACE lesions have also been observed after AF ablation. 800 The prothrombotic state associated with AF ablation results in a higher, but transient, thromboembolism risk in patients with AF who were identified as low-risk before ablation.…”

Safety of Continuous Periprocedural Rivaroxaban for Patients Undergoing Left Atrial Catheter Ablation Procedures

“…1 Periprocedural thromboembolic events and bleeding complications are among the most important and insidious complications of AF ablation. 2 A proper periprocedural anticoagulation management is mandatory to minimize the thromboembolic and bleeding risk. 3,4 Clinical Perspective on p 582…”

Efficacy and Safety of Periprocedural Dabigatran in Patients Undergoing Catheter Ablation of Atrial Fibrillation

“…[1][2][3] Several studies have shown that the periprocedural continuation of therapeutic warfarin could reduce thromboembolic complications without increasing the risk of hemorrhagic complications. [4][5][6][7][8][9] In addition, it has been reported that cardiac tamponade as a complication of AF ablation is not difficult to manage when the procedure is performed under therapeutic international normalized ratio (INR). 9 …”