Melissa H. Kong

Peri-procedural interrupted oral anticoagulation for atrial fibrillation ablation: comparison of aspirin, warfarin, dabigatran, and rivaroxaban

Aims Atrial fibrillation ablation requires peri-procedural oral anticoagulation (OAC) to prevent thromboembolic events. There are several options for OAC. We evaluate peri-procedural AF ablation complications using a variety of peri-procedural OACs. Methods and results We examined peri-procedural OAC and groin, bleeding, and thromboembolic complications for 2334 consecutive AF ablations using open irrigated-tip radiofrequency (RF) catheters. Pre-ablation OAC was warfarin in 1113 (47.7%), dabigatran 426 (18.3%), rivaroxaban 187 (8.0%), aspirin 472 (20.2%), and none 136 (5.8%). Oral anticoagulation was always interrupted and intraprocedural anticoagulation was unfractionated heparin (activated clotting time, ACT = 237 ± 26 s). Pre- and post-OAC drugs were the same for 1591 (68.2%) and were different for 743 (31.8%). Following ablation, 693 (29.7%) were treated with dabigatran and 291 (12.5%) were treated with rivaroxaban. There were no problems changing from one OAC pre-ablation to another post-ablation. Complications included 12 (0.51%) pericardial tamponades [no differences for dabigatran (P = 0.457) or rivaroxaban (P = 0.163) compared with warfarin], 12 (0.51%) groin complications [no differences for rivaroxaban (P = 0.709) and fewer for dabigatran (P = 0.041) compared with warfarin]. Only 5 of 2334 (0.21%) required blood transfusions. There were two strokes (0.086%) and no transient ischaemic attacks (TIAs) in the first 48 h post-ablation. Three additional strokes (0.13%), and two TIAs (0.086%) occurred from 48 h to 30 days. Only one stroke had a residual deficit. Compared with warfarin, the neurologic event rate was not different for dabigatran (P = 0.684) or rivaroxaban (P = 0.612). Conclusion Using interrupted OAC, low target intraprocedural ACT, and irrigated-tip RF, the rate of peri-procedural groin, haemorrhagic, and thromboembolic complications was extremely low. There were only minimal differences between OACs. Low-risk patients may remain on aspirin/no OAC pre-ablation. There are no problems changing from one OAC pre-ablation to another post-ablation.

Predicting atrial fibrillation ablation outcome: The CAAP-AF score.

BACKGROUNDnPatients with a variety of clinical presentations undergo atrial fibrillation (AF) ablation. Long-term ablation success rates can vary considerably.nnnOBJECTIVEnThe purpose of this study was to develop a clinical scoring system to predict long-term freedom from AF after ablation.nnnMETHODSnWe retrospectively derived the scoring system on a development cohort (DC) of 1125 patients undergoing AF ablation and tested it prospectively in a test cohort (TC) of 937 patients undergoing AF ablation.nnnRESULTSnThe demographics of the DC patients were as follows: age 62.3 ± 10.3 years, male sex 801 (71.2%), left atrial size 4.30 ± 0.69 cm, paroxysmal AF 348 (30.9%), number of drugs failed 1.3 ± 1.1, hypertension 525 (46.7%), diabetes 100 (8.9%), prior stroke/transient ischemic attack 78 (6.9%), prior cardioversion 528 (46.9%), and CHADS2 score 0.87 ± 0.97. Multivariate analysis showed 6 independent variables predicting freedom from AF after final ablation: coronary artery disease (P = .021), atrial diameter (P = .0003), age (P = .004), persistent or long-standing AF (P < .0001), number of antiarrhythmic drugs failed (P < .0001), and female sex (P = .0001). We created a scoring system (CAAP-AF) using these 6 variables, with scores ranging from 0 to 13 points. The 2-year AF-free rates by CAAP-AF scores were as follows: 0 = 100%, 1 = 95.7%, 2 = 96.3%, 3 = 83.1%, 4 = 85.5%, 5 = 79.9%, 6 = 76.1%, 7 = 63.4%, 8 = 51.1%, 9 = 53.6%, and ≥10 = 29.1%. Ablation success decreased as CAAP-AF scores increased (P < .0001). The CAAP-AF score also predicted freedom from AF in the TC. The 2-year Kaplan-Meier AF-free rates by CAAP-AF scores were as follows: 0 = 100%, 1 = 87.0%, 2 = 89.0%, 3 = 91.6%, 4 = 90.5%, 5 = 84.4%, 6 = 70.1%, 7 = 71.0%, 8 = 60.7%, 9 = 68.9%, and ≥10 = 51.3%. As CAAP-AF scores increased, 2-year freedom from AF in the TC decreased (P < .0001).nnnCONCLUSIONnAn easily determined clinical scoring system was derived retrospectively and applied prospectively. The CAAP-AF score predicted freedom from AF after ablation in both a DC and a TC of patients undergoing AF ablation. The CAAP-AF score provides a realistic AF ablation outcome expectation for individual patients.

Discontinuing anticoagulation following successful atrial fibrillation ablation in patients with prior strokes

PurposeThis study was conducted to examine the outcomes in patients with prior stroke/transient ischemic attack (CVA/TIA) after atrial fibrillation (AF) ablation and the feasibility of discontinuing oral anticoagulation (OAC).MethodsThis study examined long-term outcomes following AF ablations in 108 patients with a history of prior thromboembolic CVA/TIA. Because of risks of OAC, we frequently discontinue OAC in these patients after successful ablation. These patients understand the risks/benefits of discontinuing OAC and remain on OAC for a longer time following successful AF ablation, compared to our patients without prior CVA/TIA.ResultsPatient age was 66.2u2009±u20099.0xa0years with an average CHADS2 scoreu2009=u20093.0u2009±u20090.9 and CHA2DS2-VASc scoreu2009=u20094.1u2009±u20091.4. Following 1.24 ablations, 71 (65.7xa0%) patients were AF free 2.8u2009±u20091.6 (median 2.3)u2009years after their last ablation. OAC was discontinued in 55/71 (77.5xa0%) patients an average of 7.3xa0months following the final ablation. These 55 patients had 2.2u2009±u20091.3 (median 1.8)u2009years of follow-up off of OAC. Kaplan–Meier analysis suggests little AF recurrence >1xa0year following initial or final ablations, suggesting that 1xa0year post successful ablation may be the appropriate time to consider discontinuing OAC. Thirty-seven patients had AF postablation, and 32/37 (86.5xa0%) remained on OAC. One patient with a mechanical valve had a stroke despite OAC. Bleeding occurred in 8.3xa0% of patients on OAC and 0xa0% of patients off OAC (Pu2009=u20090.027).ConclusionsPatients with prior CVA/TIAs, who undergo successful AF ablation, have a low incidence of subsequent thromboembolic events. Most patients who appear AF free postablation may be able to discontinue OAC after successful ablation with a low thromboembolic risk and with a reduced bleeding risk.

Physician-controlled costs: the choice of equipment used for atrial fibrillation ablation.

PurposeAtrial fibrillation (AF) ablation uses expensive technology and equipment. Physicians have considerable latitude over equipment choice. Average Medicare reimbursement is

Prior antiarrhythmic drug use and the outcome of atrial fibrillation ablation

10,338 for uncomplicated AF ablations. The purpose of this study is to evaluate the cost of special equipment chosen by physicians to perform AF ablation.MethodsWe obtained the list price cost of special capital equipment and of disposable equipment (intracardiac ultrasound probes, transseptal needles/sheaths, and ablation/recording catheters) commonly used for radiofrequency (RF) AF ablation. We also evaluated the equipment cost of using robotic magnetic navigation and cryoablation. Then we evaluated costs for several physician equipment choice scenarios.ResultsUsing open irrigated-tip catheters, the lowest estimated cost-per-case for manual RF ablation of AF was

Trends in atrial fibrillation ablation: have we maximized the current paradigms?

6,637, and the highest estimated cost of manual RF ablation was

Gender Differences of Thromboembolic Events in Atrial Fibrillation

12,603. Assuming 200 AF ablations/year and a 6-year magnet life, the cost-per-case of using magnetic navigation ablation ranged from

Atrial fibrillation ablation using open-irrigated tip radiofrequency: Experience with intraprocedural activated clotting times ≤210 seconds

12,261–

Atrial Arrhythmia Burden on Long-Term Monitoring in Asymptomatic Patients Late After Atrial Fibrillation Ablation

15,464. The cost-per-case using cryoballoons alone ranged from

Ablation of atypical atrial flutters using ultra high density-activation sequence mapping

12,847–