The use of anticoagulation during the periprocedure period of atrial fibrillation ablation

Abstract

The use of atrial fibrillation ablation has increased over the past decade. Along with technique and technology advances that have improved the success of ablation, strides have been made in minimizing thromboembolic and bleeding risks and in the availability of a broader choice of anticoagulants. Research is ongoing to identify patients most suitable for ablation and to determine the long-term efficacy and safety of this treatment option.

Catheter Ablation of Lone Atrial Fibrillation

“…Another strategy is increasingly applied and it consists of continuous warfarin therapy throughout the whole periprocedural period, without interruption. During the procedure, INR is maintained in lower therapeutic range of 2 to 2.5, and application of subcutaneous LMWH in periprocedural period is not necessary [158,160]. The main concern with uninterrupted warfarin strategy is related to possible procedural bleeding.…”

“…Optimal duration of anticoagulant therapy after the procedure is not completely clarified. In the weeks after the ablation procedure, damaged endothelium represents possible nidus for thrombus formation [120,158]. Although most of AF recurrences are registered in the first 1-2 years, the attention is drawn to appearance of later arrhythmia relapse [79].…”

“…The patients should be anticoagulated systemically with a vitamin K antagonist at the therapeutic level (International Normalized Ratio [INR] between 2 and 3) or with a new oral anticoagulant drug (direct thrombin or Factor Xa inhibitor) for at least 3-4 weeks prior to the procedure [1,3,120]. TEE before ablation procedure probably is not necessary in all patients, but it could be very important for selected high risk patients, such as those with persistent AF, patients having AF on the day of the procedure, especially if episode of AF lasted >48h, as well as patients with high a CHADS 2 score of ≥2, a subtherapeutic INR of <2 during the previous weeks and patients with considerably dilated LA [158]. Only with younger patients with low CHADS 2 score ≤1, normal LA dimension and paroxysmal lone AF, presenting in sinus rhythm at ablation procedure, simplified alternative therapy only with aspirin, can be considered [159].…”

“…According to the classical strategy, warfarin is interrupted 3-4 days before the procedure and during those days it should be overlapped with low-molecular-weight heparin (LMWH: enoxaparin or dalteparin). After procedure, warfarin is reinitiated (with LMWH bridging until the therapeutic INR of >2 is reached) [120,158]. Another strategy is increasingly applied and it consists of continuous warfarin therapy throughout the whole periprocedural period, without interruption.…”

Clinical considerations of anticoagulation therapy for patients with atrial fibrillation

“…and 'Discontinuation of systemic anticoagulation therapy post ablation is not recommended in patients who are at high risk of stroke as estimated by currently recommended schemes (CHADS 2 or CHA 2 DS 2 -VASc)' (Calkins et al, 2012). There is highly consistent evidence from observational studies that a continued warfarin strategy during radio frequency catheter ablation of AF reduces the risk of thromboembolic complications without increasing the risk of bleeding (Santangeli et al, 2012;Verma and Tsang, 2012), which appears at present to be a problem. It is assumed that patients taking dabigatran are unlikely to require bridge therapy because of a predictable anticoagulant effect and a rapid onset of action.…”