Periprocedural Management of Novel Oral Anticoagulants During Atrial Fibrillation Ablation: Controversies and Review of the Current Evidence

Abstract

Oral anticoagulation (OAC) has been the cornerstone for the prevention of thromboembolic complications in patients with atrial fibrillation (AF) at significant risk of stroke. Catheter ablation is an established efficacious technique for the treatment of AF. Ameliorating the risk of stroke or transient ischaemic attack (TIA) in patients with AF undergoing ablation requires meticulous planning of pharmacotherapy. The advent of non-vitamin K oral anticoagulants (NOACs) has broadened the therapeutic scope, representing a viable alternative to traditional vitamin K antagonists (VKA) in non-valvular AF. Potential advantages of NOACs include greater pharmacokinetic predictability, at least comparable efficacy as compared to VKA and a superior haemorrhagic complication profile. However, robust evidence for the safety and efficacy of periprocedural NOAC use for AF ablation remains uncertain with a non-uniform clinical approach between and within institutions. The following review will summarise the current and emerging evidence on periprocedural management of NOACs in patients undergoing catheter ablation of AF. An overview of NOAC pharmacology will provide a foundation for the review of reversal agents in the context of catheter ablation of AF. The purpose of the review is to outline key studies and identify key areas for further critical research with the ultimate aim of developing evidence-based guidelines for optimal care.

Report of periprocedural oral anticoagulants in catheter ablation for atrial fibrillation: The Japanese Catheter Ablation Registry of Atrial Fibrillation (J‐CARAF)

“…However, several other studies have concluded that dabigatran may safely be substituted for warfarin [2,9–11,13,15]. Although there are several articles that report an increase or decrease in adverse events with periprocedural DOACs, most studies find no remarkable differences in bleeding and thrombotic events between warfarin and DOACs [19].…”

Contemporary Management of Direct Oral Anticoagulants During Cardioversion and Ablation for Nonvalvular Atrial Fibrillation

“…If the patient remains in normal sinus rhythm 2–3 months after procedure, stopping long‐term anticoagulation can be considered. Importantly, failure to achieve and maintain a therapeutic INR in the previous 3 weeks or failure to achieve and maintain an ACT of > 300 seconds during the procedure have been associated with an elevated risk of thrombosis in the periprocedural window . It is against this historical backdrop that alternative management strategies for anticoagulation for ablation procedures can be considered in the present day.…”

“…Importantly, failure to achieve and maintain a therapeutic INR in the previous 3 weeks or failure to achieve and maintain an ACT of > 300 seconds during the procedure have been associated with an elevated risk of thrombosis in the periprocedural window. 38 It is against this historical backdrop that alternative management strategies for anticoagulation for ablation procedures can be considered in the present day. Although appropriate anticoagulation during AF catheter ablation is necessary to minimize thromboembolic risk, it also increases the risk of bleeding.…”

Periprocedural Management of Direct Oral Anticoagulants Surrounding Cardioversion and Invasive Electrophysiological Procedures

“…However, the failure to maintain a therapeutic INR over the preceding 3 weeks or to maintain an activated clotting time (ACT) of >300 seconds during ablation were associated with elevated thrombosis risk in the periprocedural window. 45 Current guidelines recommend 3 weeks of anticoagulation before catheter ablation in patients with AF ≥48 hours to mitigate thrombosis risk. 1 , 2 Alternatively, TEE may allow ablation to proceed without delay.…”