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
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