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Ural KG, Moridzadeh SS, Busch EH, Masri OE, Burton JH, Morin DP. Use of a New Standardized Unfractionated Heparin Protocol for Left-Sided Ablation Procedures Improves Time in the Therapeutic ACT Range. J Cardiothorac Vasc Anesth 2024; 38:67-72. [PMID: 38030427 DOI: 10.1053/j.jvca.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/31/2023] [Accepted: 11/05/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVES This study evaluated whether a novel standardized heparin dosing protocol used during atrial fibrillation catheter ablation resulted in a higher percentage of therapeutic activated clotting time (ACT) values compared to historic nonstandardized procedures. DESIGN A retrospective cohort study SETTING: This study was conducted at Ochsner Medical Center, the largest tertiary-care teaching hospital in New Orleans, LA PARTICIPANTS: Patients undergoing catheter-based atrial fibrillation ablation INTERVENTIONS: The authors implemented a standardized heparin protocol, and enrolled 202 patients between November 2020 and March 2021. The historic controls consisted of 173 patients who underwent atrial fibrillation ablation between April 2020 and September 2020. Heparin administration in the control group was based on physician preference and was nonstandardized. MEASUREMENTS AND MAIN RESULTS The primary endpoint was the percentage of intraprocedural ACTs in therapeutic range (≥300 to <450 s). Secondary endpoints included first measured ACT at ≥300 s and percent of measured ACTs in the supratherapeutic range (>450 s). Comparisons were performed using chi-squared tests or Fisher exact tests. Patients in the intervention group had a higher mean percentage of ACTs in the therapeutic range compared to the control group (84.9% vs. 75.8%, p<0.001). More patients in the intervention group reached therapeutic ACT on the first measurement compared to the control group (70.3% vs. 31.2%, p<0.001). CONCLUSION During catheter-based cardiac ablation procedures, a novel standardized unfractionated heparin dosing protocol resulted in a higher percentage of ACTs in the target range, and a higher proportion of initial ACTs in the therapeutic range compared with baseline nonstandardized heparin dosing.
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Affiliation(s)
- Kelly G Ural
- Ochsner Clinic Foundation, 1514 Jefferson Hwy., New Orleans, LA 70121; The University of Queensland Medical School, Ochsner Clinical School, 1401 Jefferson Hwy., New Orleans, LA 70121.
| | - Sina S Moridzadeh
- The University of Queensland Medical School, Ochsner Clinical School, 1401 Jefferson Hwy., New Orleans, LA 70121.
| | - Eric H Busch
- Ochsner Clinic Foundation, 1514 Jefferson Hwy., New Orleans, LA 70121.
| | - Omar El Masri
- Ochsner Clinic Foundation, 1514 Jefferson Hwy., New Orleans, LA 70121.
| | - Jeffrey H Burton
- Ochsner Clinic Foundation, 1514 Jefferson Hwy., New Orleans, LA 70121.
| | - Daniel P Morin
- Ochsner Clinic Foundation, 1514 Jefferson Hwy., New Orleans, LA 70121; The University of Queensland Medical School, Ochsner Clinical School, 1401 Jefferson Hwy., New Orleans, LA 70121.
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2
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Tang S, Hu X, Bao W, Li F, Ge L, Wei H, Zhang Q, Zhang B, Zhang C, Wang Z, Li C. Development and Validation of a Nomogram Model Affecting the ACT Targeting Rate During Radiofrequency Ablation of Atrial Fibrillation in China. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07450-3. [PMID: 37160503 DOI: 10.1007/s10557-023-07450-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 05/11/2023]
Abstract
CONTEXT A nomogram model affecting the activated clotting time (ACT) targeting rate during radiofrequency ablation of atrial fibrillation (RFCA) in China. PURPOSE The aim of this study is to develop and validate a nomogram model for predicting the activated clotting time targeting rate after the initial bolus heparin dosages during the radiofrequency catheter ablation of atrial fibrillation in China. METHODS AND RESULTS A retrospective observational study was conducted on the data of 465 patients with atrial fibrillation who underwent radiofrequency catheter ablation (RFCA) from October 2019 to June 2022. All patients were randomized into a training cohort (70%; n = 325) and a validation cohort (30%; n = 140). Independent risk factors were identified using univariate and multifactorial logistic regression analysis. The predictive nomogram model was established using R software. The nomogram was developed and evaluated based on differentiation, calibration, and clinical efficacy using concordance statistic (C-statistic), calibration plots, and decision curve analysis (DCA), respectively. The nomogram was established using three variables, including sex (OR 1.01, 95% CI 0.29-1.76, P = 0.007), heparin dose (OR 0.04; 95%CI 0.02-0.05, P < 0.001), and the baseline ACT (OR 0.03; 95%CI 0.02-0.04, P < 0.001). The C-statistic of the nomogram was 0.736 (95%CI 0.675-0.732) in the training cohort and 0.700 (95%CI 0.622-0.721) in the validation cohort. The calibration plots showed good agreement between the predictions and observations in the training and validation cohorts. The clinical decision curve also proves that the map is useful in clinical settings. CONCLUSION The nomogram model has good discrimination and accuracy, which can screen attainment groups intuitively and individually, and has a certain predictive value for the probability of ACT reaching the target after the adequate dosage of initial heparin in Chinese patients with atrial fibrillation.
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Affiliation(s)
- Shiyun Tang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Xiaoqin Hu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Wei Bao
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Fei Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Liqi Ge
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Hui Wei
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Quan Zhang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Baixiang Zhang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Chaoqun Zhang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China
| | - Zhirong Wang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China.
| | - Chengzong Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People's Republic of China.
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Muller M, Godet J, Delabranche X, Sattler L, Millard D, Marzak H, Mertes PM, Steib A, Grunebaum L, Jesel L, Tacquard CA. Study of Modifications Induced by Continued Direct Oral Anticoagulant Therapy during Atrial Fibrillation Ablation Procedures on Standard Hemostasis Parameters. J Clin Med 2023; 12:jcm12062236. [PMID: 36983237 PMCID: PMC10054854 DOI: 10.3390/jcm12062236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/05/2023] [Accepted: 03/11/2023] [Indexed: 03/15/2023] Open
Abstract
Background: Unfractionated heparin (UFH) is used as an anticoagulant during the atrial fibrillation (AF) ablation procedure to prevent the occurrence of thromboembolic events. Guidelines recommend an activated clotting time (ACT) greater than 300 s (s) based on studies of patients treated with vitamin K antagonist (VKA) for their AF. However, direct oral anticoagulants (DOACs) have supplanted VKAs in AF and are now used as first-line therapy. It is recommended not to interrupt them during the procedure, which could interfere with the ACT measures. Objective: To assess the real-life relationship between ACT, DOAC concentrations, and UFH anti-Xa activity in patients treated by uninterrupted DOAC therapy. Methods: We conducted a single-center retrospective study. We analyzed consecutive patients with AF who underwent catheter ablation under DOAC therapy. Results: In total, 40 patients were included, including 15 (37.5%), 20 (50.0%), and 5 (12.5%) on rivaroxaban, apixaban, and dabigatran, respectively. Baseline ACT was significantly lower in the apixaban group. ACT was linearly correlated with the residual concentration of apixaban and dabigatran but not with rivaroxaban. After UFH injection, ACT was linearly correlated with the anti-Xa activity, regardless of DOAC. Patients in the apixaban group received a higher total dose of UFH during the procedure to achieve a target ACT > 300 s, which resulted in significantly higher anti-Xa activity during the procedure. Conclusion: Our results raise the question of optimal management of intra-procedural heparin therapy and highlight the limitations of the ACT test, particularly in patients on apixaban.
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Affiliation(s)
- Marie Muller
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Julien Godet
- Groupe Méthodes en Recherche Clinique (GMRC), Hôpitaux Universitaires de Strasbourg, Hôpital Civil, 67000 Strasbourg, France
| | - Xavier Delabranche
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Laurent Sattler
- Laboratoire d’Hématologie, Unité Hémostase, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - David Millard
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Halim Marzak
- Service de Cardiologie, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Paul Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Annick Steib
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Lelia Grunebaum
- Laboratoire d’Hématologie, Unité Hémostase, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Laurence Jesel
- Service de Cardiologie, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
- UMR 1260 INSERM Nanomedecine Regenerative, CRBS, Strasbourg University, 67200 Strasbourg, France
| | - Charles Ambroise Tacquard
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
- Correspondence:
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Hardy M, Douxfils J, Dincq AS, Sennesael AL, Xhaet O, Mullier F, Lessire S. Uninterrupted DOACs Approach for Catheter Ablation of Atrial Fibrillation: Do DOACs Levels Matter? Front Cardiovasc Med 2022; 9:864899. [PMID: 35425821 PMCID: PMC9001940 DOI: 10.3389/fcvm.2022.864899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022] Open
Abstract
Most patients present for catheter ablation of atrial fibrillation (CAAF) with residual or full effect of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). In daily practice, it has been observed that the activated clotting time (ACT) was actually poorly sensitive to the effect of DOACs and that patients on DOACs required more unfractionated heparin (UFH) to achieve the ACT target of 300 s during the procedure, leading some authors to worry about potential overdosing. Conversely, we hypothesize that these higher doses of UFH are necessary to achieve adequate hemostasis during CAAF regardless of the residual effect of DOACs. During CAAF, thrombosis is promoted mainly by the presence of thrombogenic sheaths and catheters in the bloodstream. Preclinical data suggest that only high doses of DOACs are able to mitigate catheter-induced thrombin generation, whereas low dose UFH already do so. In addition, the effect of UFH seems to be lower in patients on DOACs, compared to patients on VKAs, explaining part of the differences observed in heparin requirements. Clinical studies could not identify increased bleeding risk in patients on DOACs compared to those on VKAs despite similar efficacy during CAAF procedures. Moreover, targeting a lower ACT was associated with an increased periprocedural thrombotic risk for both DOAC and VKA patients. Therefore, the low sensitivity of the ACT to the residual effect of DOACs should not be a major concern in its use in the interventional cardiology laboratory.
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Affiliation(s)
- Michael Hardy
- Université catholique de Louvain, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Centre Hospitalier Universitaire UCL Namur, Namur, Belgium
- Université catholique de Louvain, Department of Anesthesiology, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Centre Hospitalier Universitaire UCL Namur, Namur, Belgium
- *Correspondence: Michael Hardy
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for LIfe Sciences, University of Namur, Namur, Belgium
- QUALIblood s.a., Namur, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, Department of Anesthesiology, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Centre Hospitalier Universitaire UCL Namur, Namur, Belgium
| | - Anne-Laure Sennesael
- Université catholique de Louvain, Pharmacy Department, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Centre Hospitalier Universitaire UCL Namur, Namur, Belgium
| | - Olivier Xhaet
- Université catholique de Louvain, Department of Cardiology, Namur Thrombosis and Hemostasis Center, Centre Hospitalier Universitaire UCL Namur, Namur, Belgium
| | - Francois Mullier
- Université catholique de Louvain, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Centre Hospitalier Universitaire UCL Namur, Namur, Belgium
| | - Sarah Lessire
- Université catholique de Louvain, Department of Anesthesiology, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Centre Hospitalier Universitaire UCL Namur, Namur, Belgium
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Running after Activated Clotting Time Values in Patients Receiving Direct Oral Anticoagulants: A Potentially Dangerous Race. Results from a Prospective Study in Atrial Fibrillation Catheter Ablation Procedures. J Clin Med 2021; 10:jcm10184240. [PMID: 34575348 PMCID: PMC8465849 DOI: 10.3390/jcm10184240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/13/2021] [Accepted: 09/15/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Activated Clotting Time (ACT) guided heparinization is the gold standard for titrating unfractionated heparin (UFH) administration during atrial fibrillation (AF) ablation procedures. The current ACT target (300 s) is based on studies in patients receiving a vitamin K antagonist (VKA). Several studies have shown that in patients receiving Direct Oral Anticoagulants (DOACs), the correlation between ACT values and UFH delivered dose is weak. Objective: To assess the relationship between ACT and real heparin anticoagulant effect measured by anti-Xa activity in patients receiving different anticoagulant treatments. Methods: Patients referred for AF catheter ablation in our centre were prospectively included depending on their anticoagulant type. Results: 113 patients were included, receiving rivaroxaban (n = 30), apixaban (n = 30), dabigatran (n = 30), and VKA (n = 23). To meet target ACT, a higher UFH dose was required in DOAC than VKA patients (14,077.8 IU vs. 9565.2 IU, p < 0.001), leading to a longer time to achieve target ACT (46.5 min vs. 27.3 min, p = 0.001). The correlation of ACT and anti-Xa activity was tighter in the VKA group (Spearman correlation ρ = 0.53), compared to the DOAC group (ρ = 0.19). Despite lower ACT values in the DOAC group, this group demonstrated a higher mean anti-Xa activity compared to the VKA group (1.56 ± 0.39 vs. 1.14 ± 0.36; p = 0.002). Conclusion: Use of a conventional ACT threshold at 300 s during AF ablation procedures leads to a significant increase in UFH administration in patients treated with DOACs. This increase corresponds more likely to an overdosing than a real increase in UFH requirement.
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Zeljkovic I, Brusich S, Scherr D, Velagic V, Traykov V, Pernat A, Anic A, Szavits Nossan J, Jan M, Bakotic Z, Pezo Nikolic B, Radeljic V, Bojko A, Benko I, Manola S, Pavlovic N. Differences in activated clotting time and total unfractionated heparin dose during pulmonary vein isolation in patients on different anticoagulation therapy. Clin Cardiol 2021; 44:1177-1182. [PMID: 34196416 PMCID: PMC8364723 DOI: 10.1002/clc.23681] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 06/11/2021] [Accepted: 06/16/2021] [Indexed: 02/05/2023] Open
Abstract
Background Periprocedural pulmonary vein isolation (PVI) anticoagulation requires balancing between bleeding and thromboembolic risk. Intraprocedural anticoagulation is monitored by activated clotting time (ACT) with target value >300 s, and there are no guidelines specifying an initial unfractionated heparin (UFH) dose. Methods We aimed to assess differences in ACT values and UFH dosage during PVI in patients on different oral anticoagulants. We conducted an international, multi‐center, registry‐based study. Consecutive patients with atrial fibrillation (AF) undergoing PVI, on uninterrupted anticoagulation therapy, were analyzed. Before transseptal puncture, UFH bolus of 100 IU/kg was administered regardless of the anticoagulation drug. Results Total of 873 patients were included (median age 61 years, IQR 53–66; female 30%). There were 248, 248, 189, 188 patients on warfarin, dabigatran, rivaroxaban, and apixaban, respectively. Mean initial ACT was 257 ± 50 s, mean overall ACT 295 ± 45 s and total UFH dose 158 ± 60 IU/kg. Patients who were receiving warfarin and dabigatran compared to patients receiving rivaroxaban and apixaban had: (i) significantly higher initial ACT values (262 ± 57 and 270 ± 48 vs. 248 ± 42 and 241 ± 44 s, p < .001), (ii) significantly higher ACT throughout PVI (309 ± 46 and 306 ± 44 vs. 282 ± 37 and 272 ± 42 s, p < .001), and (iii) needed lower UFH dose during PVI (140 ± 39 and 157 ± 71 vs. 171 ± 52 and 172 ± 70 IU/kg). Conclusion There are significant differences in ACT values and UFH dose during PVI in patients receiving different anticoagulants. Patients on warfarin and dabigatran had higher initial and overall ACT values and needed lower UFH dose to achieve adequate anticoagulation during PVI than patients on rivaroxaban and apixaban.
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Affiliation(s)
- Ivan Zeljkovic
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Sandro Brusich
- Department of Cardiology, University Hospital Centre Rijeka, Rijeka, Croatia
| | - Daniel Scherr
- Department of Cardiology, Medical University Graz, Graz, Austria
| | - Vedran Velagic
- Department of Cardiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Andrej Pernat
- Department of Cardiology, University Hospital Centre Ljubljana, Ljubljana, Slovenia
| | - Ante Anic
- Department of Cardiology, University Hospital Centre Split, Split, Croatia
| | | | - Matevz Jan
- Department of Cardiac Surgery, University Hospital Centre Ljubljana, Ljubljana, Slovenia
| | - Zoran Bakotic
- Department of Cardiology, General Hospital Zadar, Zadar, Croatia
| | - Borka Pezo Nikolic
- Department of Cardiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Vjekoslav Radeljic
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Ana Bojko
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Ivica Benko
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia.,Department of Cardiology, University Hospital Dubrava, Zagreb, Croatia
| | - Sime Manola
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia.,Department of Cardiology, University Hospital Dubrava, Zagreb, Croatia
| | - Nikola Pavlovic
- Department of Cardiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia.,Department of Cardiology, University Hospital Dubrava, Zagreb, Croatia
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