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Periprocedural Dabigatran in Atrial Fibrillation Ablation

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Periprocedural Dabigatran in Atrial Fibrillation Ablation

Editorial Comment


Evidence has been growing about performing atrial fibrillation (AF) ablation under continuous warfarin administration with a therapeutic international normalized ratio (INR) rather than bridging with low-molecular weight heparin (LMWH) during the days preceding and following the procedure. As stated by recent 2012 HRS/EHRA/ECAS expert consensus document, this strategy accounts for lower risk of thromboembolic and bleeding complications without increasing serious adverse events, while the practice of bridging with LMWH has been associated to a higher risk of such complications most likely due to unpredictable anticoagulant effects of LMWH. However, more recent studies have shown that the optimal intraprocedural INR range in order to safely perform AF ablation without discontinuing warfarin is very narrow. Of note, keeping the INR at therapeutic levels is sometimes challenging, especially in patients already taking medications that interact with the effects of oral anticoagulants.

With the recent FDA approval of the novel oral thrombin inhibitor dabigatran etexilate, and its inclusion in the international guidelines as an alternative to vitamin K antagonists (VKA) for the prevention of stroke in patients with AF, a new era in oral anticoagulation has begun. The RELY trial demonstrated that dabigatran 150 mg BID is a real alternative to warfarin in AF patients, being associated with lower rates of stroke and systemic embolism, similar rates of major hemorrhage, but, importantly, less intracranial hemorrhage rates. Moreover, dabigatran is administered with a fixed dose and requires neither anticoagulant activity monitoring nor dose adjustment, which is a further advance for patients needing oral anticoagulation and has the potential to extend such treatment to a greater population. For all those reasons, dabigatran is being used more frequently in clinical practice.

Owing to the expanding indications of AF catheter ablation and the wider use of novel oral anticoagulants, an increasing number of patients may already be taking dabigatran at the time of a planned AF ablation. Embolic stroke is one of the most feared complications of AF ablation, and factors like catheter placement and ablation in the left heart may contribute to an increased thromboembolic risk. Hence, a higher intensity of anticoagulation is warranted to reduce the risk of clot formation during the procedure, despite resulting in a higher risk of bleeding. Several studies have already investigated the use of this newer anticoagulant in the setting of AF ablation, and major–minor bleeding and thromboembolic complications have been analyzed in comparison with uninterrupted warfarin modality, with contrasting results.

In this issue of the Journal, Maddox et al. assessed the efficacy of uninterrupted dabigatran as an alternative approach to uninterrupted warfarin during AF ablation, enrolling 463 study subjects (212 in the dabigatran group and 251 in the warfarin group). Although retrospective, this is the largest series of patients using dabigatran in the setting of AF ablation published so far, and the first to report the outcome of patients with continuous periablation dabigatran use.

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