Uninterrupted treatment with novel oral anticoagulants (NOACs) during catheter ablation of atrial fibrillation (AF) is safe, reveals research presented today at EHRA EUROPACE - CARDIOSTIM 2015 by Dr Carsten Wunderlich, senior consultant in the Department of Invasive Electrophysiology, Heart Centre Dresden, Germany. Continuation of NOAC therapy was not associated with periprocedural bleeding or thromboembolic complications.
The joint meeting of the European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC) and Cardiostim is being held in Milan, Italy.
Dr Wunderlich said: "Uninterrupted treatment with NOACs during ablation of AF is a subject of intense debate. We know that anticoagulation is essential in AF patients to prevent strokes. In patients with AF that does not respond to anti-arrhythmic drugs, catheter ablation with pulmonary vein isolation is a cornerstone of therapy but this procedure is associated with some bleeding risk. This has led to the recommendation to discontinue NOACs two days before the procedure in patients with normal renal function."
But he added: "Interrupting NOACs during catheter ablation leaves patients vulnerable to thromboembolism. Two years ago in our centre this approach led to peripheral embolism in the leg of two patients and a stroke in one patient. At this point we decided not to interrupt NOAC therapy during catheter ablation in future patients."
This observational study included 549 consecutive patients with drug refractory AF who were scheduled for catheter ablation with pulmonary vein isolation at the Heart Centre Dresden. A total of 233 patients were taking a vitamin K antagonist and 316 patients were taking a NOAC. Patients continued to take their prescribed anticoagulation medication without missing any doses. After the procedure echocardiography was performed to exclude pericardial effusion and patients were followed up for six months.
No patients in either group experienced a stroke or systemic embolism. There was one pericardial effusion in the vitamin K antagonist group and two in the NOAC group. Regarding access related complications, three NOAC patients had an arteriovenous fistula compared to one on vitamin K antagonists. False aneurysms (pseudoaneurysms) were experienced by seven patients on vitamin K antagonists and two on NOACs, while three NOAC patients had groin hematoma compared to four on vitamin K antagonists.
"Our study suggests that NOACs can be continued during catheter ablation of AF without an increased risk of periprocedural bleeding or thromboembolism," said Dr Wunderlich. "The number of pericardial effusions we observed was small. Importantly, pericardial effusions in the NOAC group did not require specialised treatment - we punctured them and sucked the blood out as normal. This should dispel the fears of physicians that NOACs act differently and there is no antidote."
He added: "The results of our observational study suggest that continuous NOACs are as good as continuous vitamin K antagonists during ablation of atrial fibrillation. Our study was conducted in a high volume centre with heart surgery on site and experienced physicians doing about 1 200 ablations a year. In clinical practice we do not stop NOACs before an ablation and this is a good approach for experienced centres but I would not recommend it for all hospitals. This is a single centre experience and a randomised trial is needed before firm conclusions can be drawn."
Dr Wunderlich said the data provided the impetus for a randomised trial. Patients would take their currently prescribed medication (vitamin K antagonist or NOAC) and be randomised to continuous or interrupted therapy during catheter ablation of AF. He said: "It is already accepted that uninterrupted vitamin K antagonists is associated with lower periprocedural complications than discontinuation of the drug and bridging with fractionated heparin. A randomised trial would give the evidence needed for uninterrupted NOAC therapy and put an end to the debate on this issue."
European Society of Cardiology