Anticoagulant Strategies for Electrophysiology Procedures

  • Stuart J. Beldner
  • David L. Stern


Electrophysiology procedures, including direct current cardioversion, catheter ablation, and implantation of devices, e.g., pacemakers, defibrillators, and left atrial appendage closure devices, carry dual risks of bleeding and thromboembolism. Many patients undergoing these procedures are maintained on anticoagulation with either warfarin or one of several direct oral anticoagulants, e.g., dabigatran, rivaroxaban, apixaban, and edoxaban. There are evidence-based periprocedural and post-procedural guidelines for anticoagulation, with the stated goals of minimizing thromboembolic risk and minimizing bleeding complications. For example, such evidence was provided in the BRUISE CONTROL trial where it was demonstrated that continuing oral anticoagulation rather than bridging to therapy with heparin reduced the incidence of clinically significant device-pocket hematoma. The ACUTE trial established transesophageal echocardiogram (TEE) and short-term anticoagulation as an alternative to therapeutic anticoagulation with dose-adjusted warfarin for 3 weeks prior to and 4 weeks post-cardioversion. Left-sided ablation procedures are typically done with heparin boluses and infusion with target ACTs of anywhere from 250 to 350 s, with the higher targets for those procedures where catheters dwell in the left atrium.


Ablation Cardioversion Electrophysiology Implantable cardioverter-defibrillator Pacemaker Procedural anticoagulation 


  1. 1.
    Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med. 1982;306:1018–22.CrossRefGoogle Scholar
  2. 2.
    Lloyd-Jones DM, Wang TJ, Leip EP, et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004;110:1042–6.CrossRefGoogle Scholar
  3. 3.
    Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864–70.CrossRefGoogle Scholar
  4. 4.
    Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation. 2012;126(7):860–5.CrossRefGoogle Scholar
  5. 5.
    January CT, Wann SL, Alpert JS, Calkins H, Cleveland JC, Writing Committee Members, ACC/AHA TaskForce Members, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130(23):2071–104.CrossRefGoogle Scholar
  6. 6.
    Dewilde WJ, Oirbans T, Verheugt FW, Kelder JC, De Smet BJ, Herrman JP, et al. WOEST study investigators. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013;381(9872):1107–15.CrossRefGoogle Scholar
  7. 7.
    Mond HG, Proclemer A. The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: calendar year 2009 – a World Society of Arrhythmia’s project. Pacing Clin Electrophysiol. 2011;34:1013–27.CrossRefGoogle Scholar
  8. 8.
    Bashore TM, Balter S, Barac A, et al. 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: A report of the American College of Cardiology Foundation Task Force on Expert Consensus documents developed in collaboration with the Society of Thoracic Surgeons and Society for Vascular Medicine. J Am Coll Cardiol. 2012;59:2221.CrossRefGoogle Scholar
  9. 9.
    Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(Suppl):e326S–50S. [Erratum, Chest. 2012;141:1129].CrossRefGoogle Scholar
  10. 10.
    Birnie DH, Healey JS, Wells GA, Verma A, Tang AS, Krahn AD, BRUISE CONTROL Investigators, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084–93.CrossRefGoogle Scholar
  11. 11.
    Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, 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 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. Heart Rhythm. 2007;4:816–61.CrossRefGoogle Scholar
  12. 12.
    Santangeli P, Di Biase L, Horton R. Ablation of atrial fibrillation under therapeutic warfarin reduces periprocedural complications: evidence from a meta-analysis. Circ Arrhythm Electrophysiol. 2012;5:302–11.CrossRefGoogle Scholar
  13. 13.
    Di Biase L, Burkhardt D, Santangeli P, et al. Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the COMPARE randomized trial. Circulation. 2014;129(25):2638–44.CrossRefGoogle Scholar
  14. 14.
    Calkins H, Gerstenfeld EP, Schilling R, et al. RE-CIRCUIT study-randomized evaluation of dabigatran etexilate compared to warfarin in pulmonary vein ablation: assessment of an uninterrupted periprocedural anticoagulation strategy. Am J Cardiol. 2015;115:154–5.CrossRefGoogle Scholar
  15. 15.
    Lakkireddy D, Reddy YM, Di Biase L, et al. Feasibility and safety of uninterrupted rivaroxaban for periprocedural anticoagulation in patients undergoing radiofrequency ablation for atrial fibrillation: results from a multicenter prospective registry. J Am Coll Cardiol. 2014;63:982–8.CrossRefGoogle Scholar
  16. 16.
    Di Biase L, Lakkireddy D, Trivedi C, et al. Feasibility and safety of uninterrupted periprocedural apixaban administration in patients undergoing radiofrequency catheter ablation for atrial fibrillation: results from a multicenter study. Heart Rhythm. 2015;12:1162–8.CrossRefGoogle Scholar
  17. 17.
    Bin Abdulhak AA, Khan AR, Tleyjeh IM, et al. Safety and efficacy of interrupted dabigatran for peri-procedural anticoagulation in catheter ablation of atrial fibrillation: a systematic review and meta-analysis. Europace. 2013;15:1412–20.CrossRefGoogle Scholar
  18. 18.
    Providencia R, Albenque JP, Combes S, et al. Safety and efficacy of dabigatran versus warfarin in patients undergoing catheter ablation of atrial fibrillation: a systematic review and meta-analysis. Heart. 2014;100:324–3.CrossRefGoogle Scholar
  19. 19.
    Baetz BE, Gerstenfeld EP, Kolansky DM, Spinler SA. Bivalirudin use during radiofrequency catheter ablation procedures in two patients with a history of heparin-induced thrombocytopenia. Pharmacotherapy. 2010;30(9):952.CrossRefGoogle Scholar
  20. 20.
    Aytemir K, Canpolat U, Yorgun H, Evranos B, Kaya EB, Şahiner ML, Özer N. Usefulness of ‘figure-of-eight’ suture to achieve haemostasis after removal of 15-French caliber femoral venous sheath in patients undergoing cryoablation. Europace. 2016;18(10):1545–50.CrossRefGoogle Scholar
  21. 21.
    Latacha MP. Using a new, smaller implantable loop recorder to aid in arrhythmia detection and anticoagulation decisions after AF ablation: one user’s experience. EP Lab Digest. 2015;15(3). Accessed 2018-01-23
  22. 22.
    Klein AL, Grimm RA, Murray RD, et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med. 2001;344(19):1411–20.CrossRefGoogle Scholar
  23. 23.
    Nagarakanti R, Ezekowitz MD, Oldgren J, Yang S, Chernick M, Aikens TH, et al. Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion. Circulation. 2011;123(2):131–6.CrossRefGoogle Scholar
  24. 24.
    Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981–92.CrossRefGoogle Scholar
  25. 25.
    Cappato R, Ezekowitz MD, Klein AL, Camm AJ, Ma CS, Le Heuzey JY, et al. Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation. Eur Heart J. 2014;35(47):3346–55.CrossRefGoogle Scholar
  26. 26.
    Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ, et al. Evidence-based management of anticoagulant therapy antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Supplement):e152S–84S.CrossRefGoogle Scholar
  27. 27.
    Reddy VY, Sievert H, Halperin J, Doshi SK, Buchbinder M, Neuzil P, PROTECT AF Steering Committee and Investigators, et al. Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial. JAMA. 2014;312(19):1988–98.CrossRefGoogle Scholar
  28. 28.
    Holmes DR Jr, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, et al. Randomized trial of LAA occlusion or is it prospective randomized evaluation of the watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64(1):1–12.CrossRefGoogle Scholar
  29. 29.
    Boersma LV, Ince H, Kische S, Pokushalov E, Schmitz T, Schmidt B, EWOLUTION Investigators, et al. Efficacy and safety of left atrial appendage closure with WATCHMAN in patients with or without contraindication to oral anticoagulation: 1-year follow-up outcome data of the EWOLUTION trial. Heart Rhythm. 2017;14(9):1302–8.CrossRefGoogle Scholar
  30. 30.
    Price MJ, Reddy VY, Valderrábano M, Halperin JL, Gibson DN, Gordon N, et al. Bleeding outcomes after left atrial appendage closure compared with long-term warfarin: a pooled, patient-level analysis of the WATCHMAN randomized trial experience. JACC Cardiovasc Interv. 2015;8(15):1925–32.CrossRefGoogle Scholar
  31. 31.
    Enomoto Y, Gadiyaram VK, Gianni C, Horton RP, Trivedi C, Mohanty S, et al. Use of non-warfarin oral anticoagulants instead of warfarin during left atrial appendage closure with the Watchman device. Heart Rhythm. 2017;14(1):19–24.CrossRefGoogle Scholar
  32. 32.
    Reddy VY, Möbius-Winkler S, Miller MA, Neuzil P, Schuler G, Wiebe J, et al. Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix feasibility study with Watchman left atrial appendage closure technology). J Am Coll Cardiol. 2013;61(25):2551–6.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of CardiologyNorthwell Health, Zucker School of Medicine at Hofstra/NorthwellManhassetUSA

Personalised recommendations