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Thromboembolic Risk and Anticoagulation Strategies in Patients Undergoing Catheter Ablation for Atrial Fibrillation

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Abstract

Periprocedural thromboembolic and hemorrhagic events are complications of percutaneous radiofrequency catheter ablation (RFA) of atrial fibrillation (AF). The management of anticoagulation before and after RFA could play an important role in the prevention of these complications. The incidence of thromboembolic events varies from 1% to 5%, depending on the ablation and the anticoagulation strategy used in the periprocedural period. The scientific evidence behind the management of anticoagulation in patients with AF undergoing RFA is scarce and is mostly based on small studies and experts’ consensus. It remains unclear whether catheter ablation for AF reduces the risk of stroke and obviates the need for anticoagulation after the procedure. Limited data are available regarding the risk of thromboembolism with and without warfarin after AF ablation. In this review we will review the most current evidence supporting the different strategies to reduce thromboembolic risk before, during, and after catheter ablation for AF.

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References

Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. Fuster V, Ryden LE, Cannom DS, et al. : ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006, 114:e257–e354.

    Article  PubMed  Google Scholar 

  2. Calkins H, Brugada J, Packer DL, et al.: HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Europace 2007, 9:335–379.

    Article  PubMed  Google Scholar 

  3. Calkins H: Catheter ablation should not be first-line therapy for atrial fibrillation. Nat Clin Pract Cardiovasc Med 2007, 4:4–5.

    Article  PubMed  Google Scholar 

  4. Cappato R, Calkins H, Chen SA, et al.: Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 2010, 3:32–38.

    Article  PubMed  Google Scholar 

  5. Cappato R, Calkins H, Chen SA, et al.: Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation. J Am Coll Cardiol 2009, 53:1798–1803.

    Article  PubMed  Google Scholar 

  6. Ren JF, Marchlinski FE, Callans DJ, et al.: Increased intensity of anticoagulation may reduce risk of thrombus during atrial fibrillation ablation procedures in patients with spontaneous echo contrast. J Cardiovasc Electrophysiol 2005, 16:474–477.

    Article  PubMed  Google Scholar 

  7. Dixit S, Marchlinski FE: How to recognize, manage, and prevent complications during atrial fibrillation ablation. Heart Rhythm 2007, 4:108–115.

    Article  PubMed  Google Scholar 

  8. Natale A, Raviele A, Arentz T, et al.: Venice Chart international consensus document on atrial fibrillation ablation. J Cardiovasc Electrophysiol 2007, 18:560–580.

    Article  PubMed  Google Scholar 

  9. Scherr D, Sharma K, Dalal D, et al.: Incidence and predictors of periprocedural cerebrovascular accident in patients undergoing catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2009, 20:1357–1363.

    Article  PubMed  Google Scholar 

  10. Bertaglia E, Zoppo F, Tondo C, et al.: Early complications of pulmonary vein catheter ablation for atrial fibrillation: a multicenter prospective registry on procedural safety. Heart Rhythm 2007, 4:1265–1271.

    Article  PubMed  Google Scholar 

  11. Lickfett L, Hackenbroch M, Lewalter T, et al.: Cerebral diffusion-weighted magnetic resonance imaging: a tool to monitor the thrombogenicity of left atrial catheter ablation. J Cardiovasc Electrophysiol 2006, 17:1–7.

    PubMed  Google Scholar 

  12. •• Di Biase L, Burkhardt JD, Mohanty P, et al.: Periprocedural stroke and management of major bleeding complications in patients undergoing catheter ablation of atrial fibrillation: the impact of periprocedural therapeutic international normalized ratio. Circulation 2010, 121:2550–2556. This multicenter database studied three different strategies for anticoagulation during catheter ablation for AF. They divided the patients into three groups: ablation with an 8-mm catheter off warfarin (group 1), ablation with an open irrigated catheter off warfarin (group 2), and ablation with an open irrigated catheter on warfarin (group 3). The authors concluded that the combination of an open irrigation ablation catheter and periprocedural therapeutic anticoagulation with warfarin may reduce the risk of periprocedural stroke without increasing the risk of pericardial effusion or other bleeding complications.

    Article  PubMed  Google Scholar 

  13. Scherr D, Dalal D, Chilukuri K, et al.: Incidence and predictors of left atrial thrombus prior to catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2009, 20:379–384.

    Article  PubMed  Google Scholar 

  14. Hussein AA, Martin DO, Saliba W, et al.: Radiofrequency ablation of atrial fibrillation under therapeutic international normalized ratio: a safe and efficacious periprocedural anticoagulation strategy. Heart Rhythm 2009, 6:1425–1429.

    Article  PubMed  Google Scholar 

  15. Wazni OM, Beheiry S, Fahmy T, et al.: Atrial fibrillation ablation in patients with therapeutic international normalized ratio: comparison of strategies of anticoagulation management in the periprocedural period. Circulation 2007, 116:2531–2534.

    Article  PubMed  Google Scholar 

  16. McCready JW, Nunn L, Lambiase PD, et al.: Incidence of left atrial thrombus prior to atrial fibrillation ablation: is pre-procedural transoesophageal echocardiography mandatory? Europace 2010, 12:927–932.

    Article  PubMed  Google Scholar 

  17. Jaber WA, White RD, Kuzmiak SA, et al.: Comparison of ability to identify left atrial thrombus by three-dimensional tomography versus transesophageal echocardiography in patients with atrial fibrillation. Am J Cardiol 2004, 93:486–489.

    Article  PubMed  Google Scholar 

  18. Wazni OM, Rossillo A, Marrouche NF, et al.: Embolic events and char formation during pulmonary vein isolation in patients with atrial fibrillation: impact of different anticoagulation regimens and importance of intracardiac echo imaging. J Cardiovasc Electrophysiol 2005, 16:576–581.

    Article  PubMed  Google Scholar 

  19. Cox JL, Ad N, Palazzo T: Impact of the maze procedure on the stroke rate in patients with atrial fibrillation. J Thorac Cardiovasc Surg 1999, 118:833–840.

    Article  CAS  PubMed  Google Scholar 

  20. Oral H, Chugh A, Ozaydin M, et al.: Risk of thromboembolic events after percutaneous left atrial radiofrequency ablation of atrial fibrillation. Circulation 2006, 114:759–765.

    Article  PubMed  Google Scholar 

  21. •• Themistoclakis S, Corrado A, Marchlinski FE, et al.: The risk of thromboembolism and need for oral anticoagulation after successful atrial fibrillation ablation. J Am Coll Cardiol 2010, 55:735–743. This manuscript is the most current scientific paper addressing thromboembolic risk in patients undergoing ablation for AF. The aim of this multicenter study was to evaluate the safety of discontinuing oral anticoagulation therapy (OAT) after apparently successful pulmonary vein isolation, and it discusses potential complications and anticoagulation strategies periprocedure. The authors concluded that the risk-benefit ratio favored the suspension of OAT after successful AF ablation even in patients at moderate-high risk of thromboembolic events. This conclusion needs to be confirmed by future large randomized trials.

    Article  PubMed  Google Scholar 

  22. Cheema A, Dong J, Dalal D, et al.: Long-term safety and efficacy of circumferential ablation with pulmonary vein isolation. J Cardiovasc Electrophysiol 2006, 17:1080–1085.

    Article  PubMed  Google Scholar 

  23. Hindricks G, Piorkowski C, Tanner H, et al.: Perception of atrial fibrillation before and after radiofrequency catheter ablation: relevance of asymptomatic arrhythmia recurrence. Circulation 2005, 112:307–313.

    Article  PubMed  Google Scholar 

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Correspondence to Juan F. Viles-Gonzalez.

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Viles-Gonzalez, J.F., Mehta, D. Thromboembolic Risk and Anticoagulation Strategies in Patients Undergoing Catheter Ablation for Atrial Fibrillation. Curr Cardiol Rep 13, 38–42 (2011). https://doi.org/10.1007/s11886-010-0153-2

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