Higher initial weight-based heparin dosing is required with direct oral anticoagulants during catheter ablation for atrial fibrillation

Payne, Jason; Koerber, Scott; Bickel, Trent; Ghadban, Rugheed; Flaker, Greg; Gautam, Sandeep

doi:10.1007/s10840-019-00579-y

Cited by 17 publications

(21 citation statements)

References 24 publications

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“…In another trial Payne et al provided evidence that patients on DOACs require higher initial weight-based UFH than those on warfarin and suggested an initial UFH dose of at least 150 units/kg, particularly in those with a weight >90 kg. 18 In their prospective cohort of 25 patients who received a DOAC prior to CA-AF and were administered an initial UFH dose of 160 + 12.5 units/kg, 11 patients (44%) achieved an ACT 300 seconds at 30 minutes and only 49% of all intraprocedural ACT values were 300 seconds. Their report did not include the time of TS with respect to the initial UFH dose, the last DOAC dose was held for a wide range of 12-24 hours before the procedure and did not offer a specific UFH infusion rate or subsequent titration doses.…”

Section: Discussionmentioning

confidence: 99%

“…15 Furthermore, published data on specific UFH methods to rapidly achieve and maintain the mandatory optimal ACT intensity is currently limited in scope. [16][17][18] UFH does not distribute into muscle or fat tissues and remains exclusively in the vascular circulation. 19,20 In addition, use of actual weight in weight-based UFH dosing has resulted in increased risk of bleeding in some obese patients.…”

Section: Introductionmentioning

confidence: 99%

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Comprehensive Intraprocedural Unfractionated Heparin Protocol During Catheter Ablation of Atrial Fibrillation in the Presence of Direct Oral Anticoagulants and Wide Spectrum of Body Mass Index

Safani

Tobias

Shandling

et al. 2021

J Cardiovasc Pharmacol Ther

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Introduction: Data on optimal dosing of unfractionated heparin (UFH) in the presence of a direct oral anticoagulant (DOAC) to achieve and maintain an activated clotting time (ACT) of ≥300 seconds during catheter ablation of atrial fibrillation (CA-AF) are limited and prevalence of obesity adds to the unpredictable response to UFH. Methods and Results: One hundred seventeen consecutive patients undergoing CA-AF were prospectively administered weight-adjusted, weight-based UFH using a pre-specified detailed protocol and retrospectively analyzed. Due to lack of distribution of UFH into muscle or adipose tissue and lower degree of vascularity in the latter compartment, each patient’s ideal and actual weights were used to determine the adjusted-weight for use in all UFH doses. A UFH bolus of 200 units/kg was administered intravenously followed by an infusion of 35 units/kg/hour. The mean age was 65 years, and 85 patients (72.6%) were male. The average body mass index (BMI) was 30 (range 18-50) kg/m2. After the initial UFH bolus dose, 99 patients (84.6%) achieved ACT ≥300 sec with a mean (± SD) of 380 ± 79 sec. The mean time to reach an ACT ≥300 in all patients was 14.6 ± 12.4 minutes. Among all measured ACT values, 423 (90.8%) were ≥300 seconds. These results were consistent within all BMI categories. There were no intraprocedural thrombotic or hemorrhagic complications. Two patients (1.7%) sustained groin vascular access site hematoma without subsequent intervention and 7 patients (6%) experienced minor oozing post-procedurally. Conclusions: Our comprehensive weight-adjusted, weight-based UFH protocol, during CA-AF in presence of a DOAC, rapidly achieved and maintained an effective ACT irrespective of BMI.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Comprehensive Intraprocedural Unfractionated Heparin Protocol During Catheter Ablation of Atrial Fibrillation in the Presence of Direct Oral Anticoagulants and Wide Spectrum of Body Mass Index

Safani

Tobias

Shandling

et al. 2021

J Cardiovasc Pharmacol Ther

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“…In addition to weight, pre‐procedure OAC should be considered, given the preponderance of data indicates that ACT response differs when warfarin is compared with DOAC therapies 4,16 . Pre‐procedure DOAC results in larger required weight‐based periprocedural UFH bolus to achieve the desired ACT of ≥300 s 16,17 . Additionally, body weight has been suggested as a predictor of UFH requirement for those who are on pre‐procedure rivaroxaban, during left atrial ablation 18 …”

Section: Discussionmentioning

confidence: 99%

Protocol driven periprocedural anticoagulation for left atrial ablation

Bradley

Williamson

George

et al. 2021

Cardiovasc electrophysiol

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Introduction A weight‐based heparin dosing policy adjusted for preprocedural oral anticoagulation was implemented to reduce the likelihood of subtherapeutic dosing during left atrial catheter ablation procedures. We hypothesized that initiation of the protocol would result in a greater prevalence of therapeutic activated clotting time (ACT) values and decreased time to therapeutic ACT during left atrial ablation procedures. Methods A departmental protocol was initiated for which subjects received intravenous unfractionated heparin (UFH) to achieve and maintain a goal of ACT >300 s. Initial bolus dose was adjusted for pre‐procedure oral anticoagulation and weight as follows: 50 units/kg for those receiving warfarin, 75 units/kg for those not anticoagulated, and 120 units/kg for those on direct oral anticoagulants (DOACs). A UFH infusion was initiated at 10% of the bolus per hour. One hundred consecutive left atrial ablation procedures treated with Protocol Guided heparin dosing were compared with a retrospective consecutive cohort of Usual Care heparin dosing. Results When the Usual Care and Protocol Guided cohorts were compared, significant findings were limited to those on pre‐procedure DOAC. The initial UFH bolus increased from 99.3 ± 24.8 to 118.2 ± 22.8 units/kg (p < .001), the proportion of therapeutic ACT on the first draw after heparin administration increased from 57.7% to 76.6% (p = .010), and the time to therapeutic ACT after UFH administration decreased from 37.8 ± 19.8 to 30.2 ± 16.4 min (p = .032). Conclusion A weight‐based protocol for periprocedural UFH administration resulted in a higher proportion of therapeutic ACT values and decreased the time to therapeutic ACT for those on pre‐procedure DOAC.

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“…In terms of the initial loading dose of heparin, previous studies revealed that the administration of a higher dose of heparin was required to achieve the target ACT in AF patients with uninterrupted NOACs intake than in those with uninterrupted VKA intake. [15][16][17][18] In addition, Yamaji et al 19 reported that an adequate loading dose of heparin was different for each NOAC because NOACs have different mechanisms of action. In the present study, although the average ACT in the ACT group was over 300 seconds (335.2+-59.9), there was significant difference in mean ACT between patients who took rivaroxaban and those who took edoxaban (p=0.003).…”

Section: Discussionmentioning

confidence: 99%

Safety of a single bolus administration of heparin without the measurement of activated clotting time during cryoballoon ablation: a prospective randomized controlled trial

Ahn

Han

et al. 2021

Preprint

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Introduction: Single-shot ablation has emerged as an effective technique for index atrial fibrillation (AF) ablation, with an advantage of short procedure time. Although recent guidelines recommend peri-procedural uninterrupted oral anticoagulants (OACs), the intra-procedural anticoagulation strategy remains uncertain under non-vitamin K OACs (NOACs). We investigated procedural safety of a single bolus administration of heparin without activated clotting time (ACT) measurement during cryoballoon ablation (CBA). Methods: Two hundred patients (64.2±10.0years, 70% with non-paroxysmal AF) who underwent CBA with uninterrupted NOACs were randomly assigned to No-ACT group and ACT group. A bolus of heparin (100 U/kg) was routinely administered immediately after transseptal puncture. In the ACT group, an additional injection of heparin (30 U/kg) was administered if ACT at 30-min after the initial bolus was <300 s. Results: There were no differences in baseline characteristics including CHA2DS2-VASc score between two groups. The left atrium indwelling and procedure times were 60.4±13.1 min and 78.9±13.9 min, respectively and not significantly different between two groups. The mean ACT was 335.2±59.9 s in the ACT group. Any bleeding rate was 3.2% in all patients and there was no statistically difference in bleeding complications between two groups. In the ACT group, groin hematoma, laryngopharyngeal bleeding, and hemoptysis occurred in 3, 1, and 1 patient, respectively. Cardiac tamponade occurred in 1 patient in the No-ACT group. No thromboembolic events occurred during the 30-day follow-up after CBA. Conclusion: Single bolus administration of heparin without ACT measurement is a feasible anticoagulation strategy for CBA in patients with uninterrupted NOACs intake.

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Higher initial weight-based heparin dosing is required with direct oral anticoagulants during catheter ablation for atrial fibrillation

Cited by 17 publications

References 24 publications

Comprehensive Intraprocedural Unfractionated Heparin Protocol During Catheter Ablation of Atrial Fibrillation in the Presence of Direct Oral Anticoagulants and Wide Spectrum of Body Mass Index

Comprehensive Intraprocedural Unfractionated Heparin Protocol During Catheter Ablation of Atrial Fibrillation in the Presence of Direct Oral Anticoagulants and Wide Spectrum of Body Mass Index

Protocol driven periprocedural anticoagulation for left atrial ablation

Safety of a single bolus administration of heparin without the measurement of activated clotting time during cryoballoon ablation: a prospective randomized controlled trial

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