Management of medications pre and

post procedure

Dhiraj Gupta MD DM FRCP

Consultant Cardiologist

Liverpool Heart and Chest Hospital

• Largest Cardiothoracic Centre in the UK

• 1400 EP procedures (500 AF ablations)

• 1200 device cases

• 3000 PCI cases

• Commissioning through Evaluation selected site for LAAO/ PFO work

Liverpool Heart and Chest Hospital

Liverpool Heart and Chest Hospital

Drugs

• Anticoagulants: Warfarin and NOACs

• Antiarrhythmic drugs

• Diabetic medications and Insulin

• Others: Antihypertensives

Drugs

• Anticoagulants: Warfarin and NOACs

• Antiarrhythmic drugs

• Diabetic medications and Insulin

• Others: Antihypertensives

PVI Complications Author/year

Design Size (Patients) Stroke (%) Tamponade (%)

Stabile (CACAF)

2006 RCT 68 1.5 1.5

Oral

2006

RCT 130 0 0

Pappone

2006

RCT 99 0 0

Jais (A4)

2008

RCT 155 1 0

Wilber (Thermocool-AF)

2010

RCT 106 0 1.2

Nielsen (MANTRA PAF)

2012

RCT 146 0 0.9

Packer (STOP AF)

2013

RCT 163 1.3 2.1

Cappato

2010

Survey 16309 2.2 0.6

Deshmukh

2013

Survey 93801 0.9 1.3

Groin Complications

• Most common complications

• 2-5%, including Femoral pseudoaneurysm and AV fistulae

• Use of Vascular Ultrasound hugely decreases risk*

G Wynn et al J Cardiovasc Electrophysiol 2014;25:680-5

Complications in Current Practice

• LHCH Audit of AF procedures in 2012-2015

• 1358 cases

• Significant Complications:14 (1%)

• Cardiac Tamponade 4

• Phrenic Nerve Palsy 4

• TIA 1

• Groin Hematoma delaying discharge 5

• No death/stroke/requirement for surgery

Position Paper Recommendations

• All patients undergoing AF catheter ablation who present for the

procedure in AF should

• Be anticoagulated with a NOAC, or a VKA with a therapeutic

INR of 2.0 – 3.0 for 3 weeks prior to the procedure; or

• undergo a TEE to screen for thrombi prior to the procedure

• Post procedure, patients should receive anticoagulation for at

least 2 months

• In patients receiving a VKA, the ablation should be performed

without interruption of VKA therapy

• The VKA should not be stopped and no bridging with a low

molecular weight should be instituted

• In patients receiving a NOAC and with normal renal

function, it is reasonable to give the last dose 24 h

before the ablation. For patients on dabigatran and

renal impairment, this period of interruption is longer

• Uninterrupted NOAC therapy may be considered in

some patients undergoing ablation

• For patients in sinus rhythm and a CHA2DS2-VASc

score of 0 (males) or 1 (females), it may be considered

starting a NOAC on the day of the procedure, post-

ablation

Position Paper Recommendations

What about device implants?

In the following patient groups with AF, it is recommended

to perform device surgery without interruption of VKA

• Patients with non-valvular AF and a CHA2DS2-VASc

score of ≥3

• Patients with a CHA2DS2-VASc score of 2 due to

stroke or TIA within 3 months

• Patients with AF planned for cardioversion or

defibrillation testing at device implantation

What about Valvular AF?

In the following patient groups with prosthetic heart

valves, it is recommended to perform device surgery

without interruption of VKA

• Prosthetic mitral valve

• Caged ball or tilting disc aortic valve

• Bileaflet aortic valve prosthesis and AF and a

CHA2DS2-VASc score of ≥2

NOACs and device surgery

• Non-vitamin K oral anticoagulants should probably

be temporarily discontinued for all device surgery

• The period of discontinuation should be based on

product characteristics

• It is suggested that the first dose of NAOC should

be ≥24 – 48 h after surgery. The timing of the

resumption should be based on individual

assessment of the competing risks of stroke risk

and pocket haematoma.

AF ablation on NOAC agents

NOAC Reversal Agents

• Idarucizumab for Dabigatran reversal

• N Engl J Med 2015;373:511-20

• REVERSE-AD study: 90 patients, reversal within minutes

• EMA approved

• FDA priority review: ?approval before Xmas

• Andexanet Alfa for Xabans reversal

• currently in phase 3 clinical trials

• (ANNEXA-A [apixaban]

• ANNEXA-R [rivaroxaban]

To Bridge or Not to Bridge? Author/year Design Size

(Patients)

Continued

Warfarin

Bridging with

heparin

Tolosana et al

2009

RCT 101 Hematoma in

4/50

Hematoma in 4/51

Cheng et al

2011

RCT 100 0 2 pocket

hematomas

1 pericardial

tamponade

Birnie et al

2013

RCT 681 Hematoma

12/343(3.5%)

Hematoma

54/338 (16%)

Douketis et al

(BRIDGE)

2015

D/B

RCT

1884 Major bleeding

1.3%

Major bleeding 3.2%

Summary

• Ablation procedures are becoming safer

• Increasing data on safety of continued oral anticoagulation

• Bridging heparin to be avoided as far as possible

• Arrival of NOAC reversal agents imminent