Catheter ablation to prevent recurrent atrial fibrillation: Anticoagulation
- Rod Passman, MD, MSCE
Rod Passman, MD, MSCE
- Professor of Medicine
- Northwestern University Feinberg School of Medicine
- Section Editors
- Bradley P Knight, MD, FACC
Bradley P Knight, MD, FACC
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
- N A Mark Estes, III, MD
N A Mark Estes, III, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Tufts University School of Medicine
Ischemic stroke and systemic embolization are major causes of death and disability in patients with atrial fibrillation (AF). This topic will focus on the role of anticoagulant therapy to prevent embolization in patients scheduled to undergo catheter ablation (CA). The role of anticoagulant therapy in the broad population of patients with AF is discussed separately. (See "Atrial fibrillation: Anticoagulant therapy to prevent embolization".)
Other aspects of CA are discussed elsewhere. (See "Catheter ablation to prevent recurrent atrial fibrillation: Clinical applications" and "Maintenance of sinus rhythm in atrial fibrillation: Catheter ablation versus antiarrhythmic drug therapy" and "Overview of catheter ablation of cardiac arrhythmias" and "Patient education: Catheter ablation for the heart (The Basics)".)
OUR APPROACH TO ANTICOAGULATION
There are three periods when a decision or decisions have to be made about anticoagulation in a patient scheduled for catheter ablation (CA).
●Preprocedural - We effectively anticoagulate most patients, irrespective of CHA2DS2-VASC score (table 1) or presence or absence of sinus rhythm, with either a vitamin K antagonist (VKA) or a newer oral anticoagulant (NOAC) for three weeks prior to CA. It is reasonable to not use preprocedural anticoagulation in AF patients in sinus rhythm (and who are likely to remain in sinus rhythm for three weeks prior to the procedure) with a CHA2DS2-VASC score of 0.
●Periprocedural - We continue VKA in the periprocedural period. For most patients taking once-a-day NOACs, we hold the dose the day before and the morning of the procedure. For twice-a-day NOACs, some of our experts hold both doses the day before the procedure while others hold only the evening dose before the procedure; no drug is given the morning of the procedure. Uninterrupted dabigatran may be reasonable for the uncommon patient who is at very high risk of a periprocedural stroke. All patients receive a continuous infusion of unfractionated heparin (UFH); the activated clotting time is maintained at greater than 300 seconds during the procedure.
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- OUR APPROACH TO ANTICOAGULATION
- INCIDENCE, TIMING, AND MECHANISM OF EMBOLISM
- Asymptomatic embolism
- PREPROCEDURAL ISSUES
- Choice of anticoagulant
- Switching oral anticoagulant
- Role of TEE
- PERIPROCEDURAL ISSUES
- Management of OAC
- - Patients taking long-term vitamin K antagonist
- - Patients taking NOAC
- Use of intravenous heparin
- POSTPROCEDURAL ANTICOAGULATION
- LONG-TERM ANTICOAGULATION
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS