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

Lessire, Sarah; Leblanc, Isabelle; Dincq, Anne-Sophie; Philip, Ivan; Gouin‐Thibault, Isabelle; Godiér, Anne

doi:10.1002/clc.22944

Cited by 5 publications

(5 citation statements)

References 33 publications

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“… 27 As has been described previously, there is individual variability in response to heparin that we do not fully understand. 12 As shown in Tables 2 and 3 , using the 139 dosing algorithm cases, we are beginning to understand factors that may contribute to this variability. A next step based on the modeling shown here will be to use a larger dataset to derive and test models for initial bolus and infusion rates that take into account sex and renal function in addition to anticoagulation type, weight, and baseline ACT.…”

Section: Discussionmentioning

confidence: 99%

“…Recent reports have demonstrated unpredictable and highly variable initial levels of anticoagulation using NOACs. 2 , 12 , 13 At the University of Wisconsin, an academic center in Madison, Wisconsin, with 5 electrophysiologists performing catheter ablation during the study period, heparin dosing was inconsistent between providers and required frequent nurse-physician interactions for dosing decisions. Others have reported on similar knowledge gaps in catheter ablation for AF: (1) difficulty achieving therapeutic ACT, especially with NOACs; (2) practice variation among individual providers; and (3) lack of protocols to deliver intraprocedural anticoagulation.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Evaluation of an adaptive, rule-based dosing algorithm to maintain therapeutic anticoagulation during atrial fibrillation ablation

Kalscheur,

Martini,

Mahnke

et al. 2023

Cardiovascular Digital Health Journal

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Evaluation of an adaptive, rule-based dosing algorithm to maintain therapeutic anticoagulation during atrial fibrillation ablation

Kalscheur,

Martini,

Mahnke

et al. 2023

Cardiovascular Digital Health Journal

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“…Martin, et al reported on periprocedural management of anticoagulation during CA-AF in patients treated with apixaban, dabigatran or rivaroxaban. 30 Patients received fixed doses of UFH ranging from 4,000 to 10,000 units corresponding to doses ranging from 38 to 110 units/kg based on actual body weight. Additional UFH doses to maintain an ACT ≥ 300 seconds were left to the discretion of the electrophysiologist.…”

Section: Discussionmentioning

confidence: 99%

Comprehensive Intraprocedural Unfractionated Heparin Protocol During Catheter Ablation of Atrial Fibrillation in the Presence of Direct Oral Anticoagulants and Wide Spectrum of Body Mass Index

Safani

Tobias

Shandling

et al. 2021

J Cardiovasc Pharmacol Ther

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Introduction: Data on optimal dosing of unfractionated heparin (UFH) in the presence of a direct oral anticoagulant (DOAC) to achieve and maintain an activated clotting time (ACT) of ≥300 seconds during catheter ablation of atrial fibrillation (CA-AF) are limited and prevalence of obesity adds to the unpredictable response to UFH. Methods and Results: One hundred seventeen consecutive patients undergoing CA-AF were prospectively administered weight-adjusted, weight-based UFH using a pre-specified detailed protocol and retrospectively analyzed. Due to lack of distribution of UFH into muscle or adipose tissue and lower degree of vascularity in the latter compartment, each patient’s ideal and actual weights were used to determine the adjusted-weight for use in all UFH doses. A UFH bolus of 200 units/kg was administered intravenously followed by an infusion of 35 units/kg/hour. The mean age was 65 years, and 85 patients (72.6%) were male. The average body mass index (BMI) was 30 (range 18-50) kg/m2. After the initial UFH bolus dose, 99 patients (84.6%) achieved ACT ≥300 sec with a mean (± SD) of 380 ± 79 sec. The mean time to reach an ACT ≥300 in all patients was 14.6 ± 12.4 minutes. Among all measured ACT values, 423 (90.8%) were ≥300 seconds. These results were consistent within all BMI categories. There were no intraprocedural thrombotic or hemorrhagic complications. Two patients (1.7%) sustained groin vascular access site hematoma without subsequent intervention and 7 patients (6%) experienced minor oozing post-procedurally. Conclusions: Our comprehensive weight-adjusted, weight-based UFH protocol, during CA-AF in presence of a DOAC, rapidly achieved and maintained an effective ACT irrespective of BMI.

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“…Uninterrupted DOAC results in a large and unpredictable range of concentrations and highly variable level of anticoagulation at baseline. 21 Alternatively, it is speculated that some DOAC such as apixaban may directly inhibit the level of FXa. 16 Finally, ACT values on DOAC vary according to the device used and to the drug itself.…”

Section: Discussionmentioning

confidence: 99%

Coagulation and heparin requirements during ablation in patients under oral anticoagulant drugs

Belaid

Ribes

Voglimacci‐Stephanopoli

et al. 2020

Journal of Arrhythmia

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Background Anticoagulation during catheter ablation should be closely monitored with activated clotting time (ACT). However vitamin K antagonists (VKA) or direct oral anticoagulant drugs (DOAC) may act differently on ACT and on heparin needs. The aim of this study was to compare ACT and heparin requirements during catheter ablation under various oral anticoagulant drugs and in controls. Methods Sixty consecutive patients referred for ablation were retrospectively included: group I (n = 15, VKA), group 2 (n = 15, uninterrupted rivaroxaban), group 3 (n = 15, uninterrupted apixaban), and group 4 (n = 15, controls). Heparin requirements and ACT were compared throughout the procedure. Results Heparin requirements during the procedure were significantly lower in patients under VKA compared to DOAC, but similar between DOAC patients and controls. Activated clotting time values were significantly higher in patients under VKA compared to DOAC and similar in DOAC patients versus controls. Furthermore, anticoagulation control as evaluated by the number/proportion of ACT> 300 as well as the time passed over 300 seconds was significantly better in patients under VKA versus DOAC, without significant differences between DOAC and controls. Finally, the number of patients/ACT with excessive ACT values was significantly higher in VKA versus DOAC patients versus controls. There was no significant difference between rivaroxaban and apixaban for ACT or heparin dosing throughout the procedure. Conclusion Vitamin K antagonists allowed less heparin requirement despite reaching higher ACT values and more efficient anticoagulation control (with more excessive values) compared to patients under DOAC therapy and to controls. There was no difference in heparin requirements or ACT between DOAC patients and controls.

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

Cited by 5 publications

References 33 publications

Evaluation of an adaptive, rule-based dosing algorithm to maintain therapeutic anticoagulation during atrial fibrillation ablation

Evaluation of an adaptive, rule-based dosing algorithm to maintain therapeutic anticoagulation during atrial fibrillation ablation

Comprehensive Intraprocedural Unfractionated Heparin Protocol During Catheter Ablation of Atrial Fibrillation in the Presence of Direct Oral Anticoagulants and Wide Spectrum of Body Mass Index

Coagulation and heparin requirements during ablation in patients under oral anticoagulant drugs

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