Is transesophageal echocardiogram mandatory in patients undergoing ablation of atrial fibrillation with uninterrupted novel oral anticoagulants? Results from a prospective multicenter registry.

Abstract

BACKGROUND:

Transesophageal echocardiography (TEE) is recommended in patients undergoing atrial fibrillation (AF) ablation, but use of this strategy is variable.

OBJECTIVE:

To evaluate whether TEE is necessary before AF ablation in patients treated with novel oral anticoagulants (NOACs).

METHODS:

We performed a prospective multicenter registry of AF patients undergoing radiofrequency catheter ablation on uninterrupted NOACs (apixaban and rivaroxaban). All patients were on NOACs for at least 4 weeks before ablation. Heparin bolus was administered to all patients before transseptal catheterization to maintain a target activated clotting time above 300 seconds. A subset of 86 patients underwent brain diffuse magnetic resonance imaging (dMRI) to detect silent cerebral ischemia (SCI).

RESULTS:

A total of 970 patients (514 [53%] apixaban patients and 456 [47%] rivaroxaban patients) were enrolled for this study. The mean age was 69.5 ± 9.0 years, with 824 patients (85%) having nonparoxysmal AF, and 636 patients (65.6%) were male. The average CHA2DS2-VASc score was 3.01 ± 1.3 and CHADS2 score was ≥2 in 609 patients (62.8%). Intracardiac echocardiogram ruled out left atrial appendage thrombus in all patients whose left atrial appendage was visualized (692, 71%), and detected "smoke" in 407 patients (42%). SCI at postprocedure dMRI was detected in 2.3% (2/86). One thromboembolic event (transient ischemic attack) (0.10%) with positive dMRI occurred in a patient on uninterrupted rivaroxaban with longstanding persistent AF.

CONCLUSION:

Our study illustrates that performing AF ablation while on uninterrupted apixaban and rivaroxaban without TEE is feasible and safe. This finding has important clinical and economic relevance.

• Authors: Luigi Di Biase, David F Briceno, Chintan Trivedi, Sanghamitra Mohanty, Carola Gianni, J David Burkhardt, Prasant Mohanty, Rong Bai, Sampath Gunda, Rodney Horton, Shane Bailey, Javier E Sanchez, Amin Al-Ahmad, Patrick Hranitzky, G Joseph Gallinghouse, Yaruva Madhu Reddy, Jason Zagrodzky, Richard Hongo, Salwa Beheiry, Dhanunjaya Lakkireddy, Andrea Natale
• Journal: Heart rhythm (Heart Rhythm) Vol. 13 Issue 6 Pg. 1197-202 (06 2016) ISSN: 1556-3871 [Electronic] United States
• PMID: 26994940 (Publication Type: Journal Article, Multicenter Study)
• Copyright: Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Chemical References

• Factor Xa Inhibitors
• Pyrazoles
• Pyridones
• apixaban
• Rivaroxaban

Topics

• Aged
• Atrial Appendage (diagnostic imaging)
• Atrial Fibrillation (diagnosis, drug therapy, epidemiology, surgery)
• Blood Coagulation (drug effects)
• Brain Ischemia (etiology, prevention & control)
• Catheter Ablation (adverse effects, methods)
• Echocardiography, Transesophageal (methods)
• Factor Xa Inhibitors (therapeutic use)
• Feasibility Studies
• Female
• Humans
• Male
• Middle Aged
• Patient Safety
• Preoperative Care (methods)
• Pyrazoles (therapeutic use)
• Pyridones (therapeutic use)
• Registries (statistics & numerical data)
• Rivaroxaban (therapeutic use)
• Thrombosis (diagnosis, etiology)
• United States (epidemiology)