Uninterrupted use of direct oral anticoagulants versus vitamin K antagonists for catheter ablation of atrial fibrillatio
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Uninterrupted use of direct oral anticoagulants versus vitamin K antagonists for catheter ablation of atrial fibrillation with PVAC gold: incidence of silent cerebral microembolic events Marcus Wieczorek 1,2
&
Harilaos Bogossian 1,3 & Dirk Bandorski 4 & Reinhard Hoeltgen 2
Received: 25 July 2020 / Accepted: 4 September 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background Silent cerebral microembolic events (SCE) after duty-cycled ablation of atrial fibrillation using PVAC have been detected by cerebral magnet resonance imaging (MRI) in a substantial number of patients. The purpose of this study was to investigate if uninterrupted oral anticoagulation with non-vitamin K antagonists (NOACs) compared with vitamin K antagonists (VKA) affects the incidence of SCE after pulmonary vein isolation (PVI) using PVAC Gold. Methods Eighty-four consecutive patients (62 ± 15 years, 58% male) undergoing a first PVI were prospectively enrolled. Of these, 42 were on VKA and 42 on uninterrupted NOAC treatment. An activated clotting time (ACT) ≥ 350 s was targeted for ablation. Results Cerebral MRI the day after PVI revealed acute diffusion-weighted positive lesions in 11/42 (26%) VKA compared with 14/42 (33%) in NOAC patients (p = 0.634). No differences were found for lesion size, number of lesions/patient, and number of lesions indicating cerebral infarction (2.4% for VKA and 4.8% for NOAC patients). Seventy-five percent of NOAC patients with sporadic ACT levels < 300 s during PVI developed SCE compared with 22% of corresponding VKA patients (p = 0.030). VKA and NOAC subgroups with ACT ≥ 350 s had no reduced incidence of SCE compared with ACT 300–350 s. Conclusions A significant, but comparable, number of patients under uninterrupted anticoagulation with VKA or NOACs still experience SCE after PVAC Gold PVI. NOAC patients with sporadic subtherapeutic ACT levels during PVI are at the highest risk for SCE while permanent ACT levels ≥ 350 s did not further reduce the incidence of SCE in both groups. Keywords Uninterrupted anticoagulation . Pulmonary vein isolation . Duty-cycled ablation . Atrial fibrillation . Silent cerebral embolism
1 Introduction Pulmonary vein isolation (PVI) is now considered a cornerstone in the treatment of symptomatic patients with
* Marcus Wieczorek [email protected] 1
School of Medicine, Witten/Herdecke University, Witten, Germany
2
Department of Cardiology and Electrophysiology, St. Agnes-Hospital Bocholt, Barloer Weg 125, 46397 Bocholt, Germany
3
Department of Cardiology and Rhythmology, Ev. Krankenhaus Hagen, Brusebrinkstraße 20, 58135 Hagen, Germany
4
Faculty of Medicine, Semmelweis University Campus Hamburg, Lohmühlenstraße 5, 20099 Hamburg, Germany
atrial fibrillation (AF) [1]. In patients undergoing catheter ablation, periprocedural bleeding and thromboembolic complications are significantly reduced by uninterrupted anticoagulation with vitamin K antagonists (VKAs) as compared with bridging heparin [2–7]. However, a substantial number of pat
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