Arq. Bras. Cardiol. 2020; 114(3): 443-445
Uninterrupted Direct Oral Anticoagulants in Atrial Fibrillation Catheter Ablation: Ready for Prime Time
Rhanderson Cardoso, André D’Avila
This Short Editorial is referred by the Research article "Safety of Catheter Ablation of Atrial Fibrillation Under Uninterrupted Rivaroxaban Use".
Catheter ablation is a well-established, safe, and effective strategy to achieve rhythm control in patients with symptomatic atrial fibrillation (AF) who are either intolerant or refractory to pharmacologic rhythm control or who wish to avoid long-term use of anti-arrhythmic drugs. Historically, when vitamin-K antagonists (VKAs) were the only option for oral anticoagulation, catheter ablation was performed after interruption of the VKA for several days and a transition (bridge) to subcutaneous or parenteral anticoagulation, typically with low-molecular-weight heparin. This strategy, however, was cumbersome and fraught with bleeding complications. Furthermore, the COMPARE randomized trial and observational studies showed that the thromboembolic risk was 10 to 15-fold higher with VKAs and heparin bridging as compared to uninterrupted VKAs. After these results, uninterrupted VKAs with a therapeutic international normalized ratio (INR) became the standard of care for periprocedural anticoagulation, and patients would routinely undergo catheter ablation with INR ranging between 2 and 3.5.
This option, however, also has two important setbacks. First, ablation becomes contingent on a therapeutic INR on the day of the procedure. A supra-therapeutic INR may entail a decision to postpone the procedure or administer blood products for correction, whereas a sub-therapeutic INR would typically imply deferring ablation to another day or require IV heparin until an ideal INR is reached. Second, the use of uninterrupted VKAs conflicts with the ever growing use of direct oral anticoagulants (DOACs). Electrophysiologists planning catheter ablation for patients on DOACs are faced with the following decision: (1) transition to VKAs for uninterrupted periprocedural anticoagulation or (2) continue periprocedural DOAC.
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