Oral anticoagulant therapy for stroke prevention in patients with atrial fibrillation undergoing ablation: results from the First European Snapshot Survey on Procedural Routines for Atrial Fibrillation Ablation (ESS-PRAFA)

Abstract

The European Snapshot Survey on Procedural Routines in Atrial Fibrillation Ablation (ESS-PRAFA) is a prospective, multicentre snapshot survey of patients undergoing atrial fibrillation (AF) ablation, conducted to collect patient-based data on current clinical practices in AF ablation in context of the latest AF Guidelines and contemporary oral anticoagulant therapies. The EP Research Network Centres were asked to prospectively enrol consecutive patients during a 6-week period (September/October 2014). Data were collected via the web-based case report form. We present the results pertinent to the use of antithrombotic therapies. Thirteen countries prospectively enrolled 455 eligible consecutive patients [mean age 59 ± 10.8 years, 131 (28.8%) females]. The mean CHA2DS2-VASc score was 1.12 ± 1.06 [137 patients (30.1%) had a score of ≥2]. Before ablation, 443 patients (97.4%) were on anticoagulant therapy [143 (31.4%) on non-vitamin K antagonist oral anticoagulants (NOACs) and 264 (58.0%) on vitamin K antagonists (VKAs)]. Of the latter, 79.7% underwent ablation without VKA interruption, whilst a variety of strategies were used in patients taking NOAC. After ablation, most patients (89.3%) continued the same anticoagulant as before, and 2 (0.4%) were not prescribed any anticoagulation. At discharge, 280 patients (62.2%) were advised oral anticoagulation for a limited period of mean 3.8 ± 2.2 months. On multivariate analysis, CHA2DS2-VASc, AF duration, prior VKA use, and estimated AF ablation success were significantly associated with the decision on short-term anticoagulation. Our results show the increasing use of NOAC in patients undergoing AF ablation and emphasize the need for more information to guide the periprocedural use of both NOACs and VKAs in real-world setting.

Report of periprocedural oral anticoagulants in catheter ablation for atrial fibrillation: The Japanese Catheter Ablation Registry of Atrial Fibrillation (J‐CARAF)

“…Currently, uninterrupted warfarin therapy is considered superior to interrupted anticoagulation strategy with respect to thromboembolic and bleeding complications [5–8]. Moreover, some studies, including our previous report [2], have evaluated the safety and efficacy of direct oral anticoagulants (DOAC) in the management of AF ablation [9–18]. However, the number of subjects analyzed in earlier studies is rather small.…”

Minimally interrupted novel oral anticoagulant versus uninterrupted vitamin K antagonist during atrial fibrillation ablation

“…Despite initial concerns on the safety of using periprocedural NOAC [20], nowadays, several large RCTs have demonstrated the safety and efficacy of uninterrupted use of NOACs (i.e., dabigatran, rivaroxaban, apixaban) during AF ablation [5,6,12] (Table 3). In clinical practice, however, most centers still use a minimally interrupted NOAC strategy [16]. The European Snapshot Survey on Procedural Routines in Atrial Fibrillation Ablation (ESS-PRAFA) in 2015 demonstrated that AF ablations were performed with a minimally interrupted NOAC strategy (1-2 doses withheld) in 53% of procedures, interrupted NOAC ≥2 days in 34%, and an uninterrupted NOAC strategy in 14% [16].…”

“…However, the uninterrupted NOAC strategy does not reflect current clinical practice as most centers still use a minimally interrupted NOAC strategy [16]. There is limited data demonstrating the safety and efficacy of a minimally interrupted NOAC strategy.…”

Activated clotting time on the day of atrial fibrillation ablation for minimally interrupted and uninterrupted direct oral anticoagulation therapy: Sequential changes, differences among direct oral anticoagulants, and ablation safety outcomes

“…Warfarin, a vitamin K antagonist, has been commonly used as an oral anticoagulant during the periprocedural period of AF ablation. More recently, however, direct oral anticoagulants (DOACs) have been increasingly used for periprocedural anticoagulation therapy for AF ablation . At present, the following three perioperative DOAC anticoagulation strategies are used: uninterrupted (Unint; no discontinuation of DOACs), minimally interrupted (min‐Int; holding the morning dose on the day of ablation), and interrupted (holding doses > min‐Int holding dose).…”

“…More recently, however, direct oral anticoagulants (DOACs) have been increasingly used for periprocedural anticoagulation therapy for AF ablation. 6 At present, the following three perioperative DOAC anticoagulation strategies are used: uninterrupted (Unint; no discontinuation of DOACs), minimally interrupted (min-Int; holding the morning dose on the day of ablation), and interrupted (holding doses > min-Int holding dose). The superiority among these three anticoagulation strategies in the periprocedural period of AF ablation, however, has not been fully clarified.…”