Periprocedural anticoagulation during left atrial ablation: interrupted and uninterrupted vitamin K-antagonists or uninterrupted novel anticoagulants

Brinkmeier-Theofanopoulou et al. BMC Cardiovascular Disorders (2018) 18:71 https://doi.org/10.1186/s12872-018-0804-6 RESEARCH ARTICLE Open Access Periprocedural anticoagulation during left atrial ablation: interrupted and uninterrupted vitamin K-antagonists or uninterrupted novel anticoagulants Maria Brinkmeier-Theofanopoulou1, Panagiotis Tzamalis1, Susan Wehrkamp-Richter1, Andrea Radzewitz1, Matthias Merkel1, Gerhard Schymik1, Gesine van Mark2, Peter Bramlage2 , Claus Schmitt1 and Armin Luik1* Abstract Background: There is a lack of data on anticoagulation requirements during ablation of atrial fibrillation (AF). This study compares different oral anticoagulation (OAC) strategies to evaluate risk of bleeding and thromboembolic complications. Methods: We conducted a single-centre study in patients undergoing left atrial ablation of AF. Three groups were defined: 1) bridging: interrupted vitamin-K-antagonists (VKA), INR ≤2, and bridging with heparin; 2) VKA: uninterrupted VKA and INR of > 2; 3) DOAC: uninterrupted direct oral anticoagulants. Bleeding complications, thromboembolic events and peri-procedural heparin doses were assessed. Results: In total, 780 patients were documented. At 48 h, major complications were more common in the bridging group compared to uninterrupted VKA and DOAC groups (OR: 3.42, 95% CI: 1.29–9.10 and OR: 3.01, 95% CI: 1.19–7.61), largely driven by differences in major pericardial effusion (OR: 4.86, 95% CI: 1.56–15.99 and OR: 4.466, 95% CI, 1.52–13.67) and major vascular events (OR: 2.92, 95% CI: 0.58–14.67 and OR: 9.72, 95% CI: 1.00–94.43). Uninterrupted VKAs and DOACs resulted in similar odds of major complications (overall OR: 1.14, 95% CI: 0.44–2.92), including cerebrovascular events (OR: 1.21, 95% CI: 0.27–5.45). However, whereas only TIAs were observed in DOAC and bridging groups, strokes also occurred in the VKA group. Rates of minor complications (pericardial effusion, vascular complications, gastrointestinal hemorrhage) and major/minor groin hemorrhage were similar across groups. Conclusion: Our dataset illustrates that uninterrupted VKA and DOAC have a better risk-benefit profile than VKA bridging. Bridging was associated with a 4.5× increased risk of complications and should be avoided, if possible. Keywords: Anticoagulation management, Atrial fibrillation, DOAC, Catheter ablation, Bridging, Vitamin-K-antagonists Background Atrial fibrillation (AF) is a very common cardiac arrhythmia, associated with a high risk of thromboembolic events [1]. Paroxysmal and persistent AF is frequently treated using catheter ablation aiming at an isolation of the pulmonary vein (PVI). It requires access of the catheter to the left atrium by transseptal puncture * Correspondence: 1 Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Academic Teaching Hospital of the University of Freiburg, Moltkestrasse 90, 76133 Karlsruhe, Germany Full list of author information is available at the end of the article which confers high-risk for bleeding complications such as pericardial effusion and tamponade. In addition, cases of ablation-associated pulmonary vein (PV) stenosis, thromboembolic complications, oesophageal fistulae, and phrenic nerve palsies (PNP) have been reported [2]. Therefore anticoagulation of these patients is warranted. Based on their individual stroke risk and their risk of bleeding, patients are anticoagulated with Vitamin K Antagonists (VKA; mostly warfarin or phenprocoumon), or direct oral anticoagulants (DOAC; apixaban, dabigatran, rivaroxaban, edoxaban) [1]. Furthermore, to prevent periprocedural events, patients receive parenteral heparin. © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Brinkmeier-Theofanopoulou et al. BMC Cardiovascular Disorders (2018) 18:71 Page 2 of 10 At the time of the procedure, oral anticoagulation may be interrupted with or without heparin bridging: Until recently, guidelines recommended discontinuation of oral anticoagulants (OAC) for a number of days during the perioperative period, and its replacement by short-acting anticoagulants, such as heparins (commonly known as ‘bridging’) [3]. This recommendation has changed with the advent of DOACs, with the continuation of DOACs and VKAs during ablation today being regarded safe, in principle [4]. Nonetheless there are no standardized protocols for the periprocedural management of DOACs. This is reflected in the widely different DOAC regimens used, ranging from dropping the morning dose to giving the last dose 12–24 h before the planned ablation [5, 6]. The RE-CIRCUIT study showed for the first time that an ablation can be performed safely if an uninterrupted DOAC regime is used instead of VKA [7]. We retrospectively assessed patients with AF or left atrial flutter (AFL) undergoing catheter ablation in our institution. We stratified patients into the three principal anticoagulation strategies (bridging of VKA [Bridging], uninterrupted VKA [VKA] and uninterrupted DOAC [DOAC]) and evaluated bleeding/vascular risk and thromboembolic complications as well as the incidence of pericardial effusion. the intervention. VKAs were paused and patients bridged with low molecular weight heparin (LMWH) in patients with an international normalised ratio (INR) ≤ 2.0 on the day of hospitalisation. Phenprocoumon was paused at least 2–3 days before the procedure. Bridging with LMWH was started when INR was < 2. After the procedure unfractionated heparin (UFH) was perfused with a target activated partial thromboplastin time (aPTT) of 60–80 s until removal of the pressure bandage. If no bleeding complications were seen, LMWH was administered until an INR < 2.0 was reached. 2) The second group (VKA group, VKA) consisted of patients treated with phenprocoumon before the procedure with an INR > 2 and < 3.5 on the day of the procedure. In these patients, phenprocoumon was administered uninterruptedly. 3) The DOAC group consisted of all patients on DOACs before the procedure. The drugs used were dabigatran (110 or 150 mg twice daily [BID]), rivaroxaban (15 or 20 mg once daily [OD]) and apixaban (2,5 or 5 mg BID). All DOACs were administered without discontinuation. Last dosages of dabigatran and apixaban were administered the morning of the procedure. Patients on rivaroxaban the evening before or the morning of the procedure as per the patient’s scheduled dose. No LMWH or antidote were administered. The next dose was given t (...truncated)