Early Heparin Administration Reduces Risk for Left Atrial Thrombus Formation during Atrial Fibrillation Ablation Procedures

Abstract

Objective. Despite the use of anticoagulation during left atrial (LA) ablation procedures, ischemic cerebrovascular accidents (CVAs) are recognized as a serious complication. Heparin is usually given after safe transseptal access has been obtained, resulting in a short unprotected dwell time of catheters within the LA, which may account for CVAs. We investigated the frequency of CVAs and LA thrombus formation as detected by intracardiac ultrasound (ICE) depending on the timing of heparin administration. Methods and Results. Sixty LA ablation procedures with the use of ICE were performed in 55 patients. Patients were grouped by heparin administration after (Group I, n = 13) and before (Group II, n = 47) transseptal access. Group I patients were younger (56.6 ± 13.7 versus 65.9 ± 9.9 years, P = .01); other clinical and echocardiographic characteristics did not differ between groups. Early thrombus formation was observed in 2 (15.4%) of group I patients as compared to 0% of group II patients (P = .04). One CVA (2.1%) occurred in one group II patient without prior thrombus detection, and none occurred in group I patients (P = ns). Conclusion. Early administration of heparin reduces the risk of early intracardiac thrombus formation during LA ablation procedures. This did not result in reduced rate of CVAs.

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

“…One recommendation of the task force (Table 4) is that heparin should be administered prior to or immediately following transseptal puncture during AF ablation procedures and adjusted to achieve and maintain a target ACT (activated clotting time) of 300 to 400 s. This recommendation reflects the well-established observation that thrombi can form on the transseptal sheath and/or electrode catheter almost immediately after crossing the septum and that early heparinization substantially decreases this risk [318,[381][382][383][384][409][410][411]. More than 50% of the task force members give heparin prior to the transseptal puncture.…”

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation

“…It has been observed that thrombi can form on the transseptal sheath and/or the electrode catheter almost immediately after crossing the septum and that early heparinization substantially decreases this risk. 768 , 802 , 803 , 804 , 846 , 847 , 848 A recent meta-analysis of more than 7000 patients supports this recommendation, showing that performing ablation of AF with a target ACT >300 seconds decreases the risk of thromboembolic complications without increasing the risk of bleeding. 849 Seventy-seven percent of the writing group members administer heparin prior to the transseptal puncture.…”

2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary

“… IIb C-EO 381 , 382 , 383 , 384 , 385 , 386 During ablation Heparin should be administered prior to or immediately following transseptal puncture during AF catheter ablation procedures and adjusted to achieve and maintain an ACT of at least 300 seconds. I B-NR 369 , 380 , 381 , 382 , 387 , 388 , 389 , 390 , 391 , 392 , 393 Administration of protamine following AF catheter ablation to reverse heparin is reasonable. IIa B-NR 394 Postablation In patients who are not therapeutically anticoagulated prior to catheter ablation of AF and in whom warfarin will be used for anticoagulation postablation, low molecular weight heparin or intravenous heparin should be used as a bridge for initiation of systemic anticoagulation with warfarin following AF ablation.…”