Thromboembolic and bleeding risks in patients undergoing atrial fibrillation ablation: oral anticoagulation perspectives

ABSTRACT

Introduction: Atrial fibrillation (AF) is a cause of significant morbidity and mortality. Catheter ablation for AF (CAAF) has emerged as an effective treatment option of rhythm control for patients with symptomatic AF. However, the risk of thromboembolism and bleeding in the periprocedural period represent a worrisome complication of this therapy. The reported incidence of thromboembolic and bleeding events associated with CAAF varies from 0.9% to 5% depending on the CAAF strategy and the anticoagulation regimen used in the periprocedural period.

Areas covered: The different anticoagulation regimens used prior to, during, and after CAAF to minimize the risk of thromboembolic and bleeding events are reviewed. The use of uninterrupted oral anticoagulation and appropriate heparin dosing to achieve safe activated clotting time levels are also detailed. A comprehensive approach with assessment of individual risk for thromboembolic and bleeding complications, and understanding the pharmacokinetics of the anticoagulant agents available is also reviewed.

Expert opinion: The key advances done in the periprocedural anticoagulation field include the use of uninterrupted anticoagulation strategies in patients undergoing AF ablation and efforts to simplify the selection of patients who need LAA thrombus screening prior to ablation.

KEYWORDS:

• Atrial fibrillation
• catheter ablation
• thromboembolism
• bleeding
• anticoagulation

Article highlights

• CAAF has emerged as an effective form of rhythm control for patients with symptomatic AF, and the risk of thromboembolism and bleeding in the periprocedural period represent a worrisome complication.

• The data regarding pre-ablation TEE is largely derived from the cardioversion studies. Current guidelines recommend at least 3 weeks of effective anticoagulation (e.g. therapeutic INR and NOAC compliance) prior to ablation. This strategy has been supported by retrospective studies.

• In 2014, the results from the first randomized controlled trial (COMPARE trial) demonstrated that uninterrupted OAC with warfarin was superior to bridging with heparin products, both in terms of preventing periprocedural stroke /TIA and reducing bleeding events, in a population at high risk of embolic events.

• The use of uninterrupted NOAC in the periprocedural period of CAAF is still an area of active research and has not yet reached a consensus statement.

• Achieving ACT > 300 s decreases the risk of thromboembolic complications without increasing the risk of bleeding. Patients receiving VKAs require less heparin and reach the target ACT faster compared to patients receiving NOACs.

• Continuation or cessation of oral anticoagulation in the long term is based on multiple patient related (i.e. CHA2DS2-VASc) and procedural factors (limited vs. extensive ablation).

This box summarizes key points contained in the article.

Declaration of interest

Dr Di Biase is a consultant for Stereotaxis, Biosense Webster, Boston Scientific and St Jude Medical. Dr Di Biase received speaker honoraria/travel from Medtronic, Janssen, Pfizer, EPiEP and Biotronik. Dr. Natale has received speaker honoraria from Boston Scientific, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic and is a consultant for Biosense Webster, St. Jude Medical, and Janssen. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper has not been funded.