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Hu X, Li W, Ren B, Zeng R. Incidence of silent cerebral events detected by MRI in patients with atrial fibrillation undergoing pulsed field ablation vs thermal ablation: A systematic review and network meta-analysis. Heart Rhythm 2025:S1547-5271(25)02315-X. [PMID: 40221109 DOI: 10.1016/j.hrthm.2025.04.008] [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] [Received: 12/12/2024] [Revised: 04/01/2025] [Accepted: 04/05/2025] [Indexed: 04/14/2025]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and catheter ablation has been demonstrated to achieve superior success rates compared with antiarrhythmic drugs. However, this procedure entails certain risks, including silent cerebral events (SCEs), which may affect cognitive function. This network meta-analysis aimed to determine the global incidence of SCEs in patients with AF undergoing catheter ablation and to compare the incidence across energy sources and catheter types. Our analysis included 86 trials involving 10,456 patients with AF, with a pooled SCE incidence of 19.1%. For pulsed field ablation, the incidence of SCEs was 14.4%; thermal ablation techniques showed rates of 17.7% for radiofrequency ablation, 20.8% for cryoballoon ablation, and 32.7% for laser ablation. No significant differences were found between pulsed field ablation and thermal ablation in SCE incidence. The comparison of SCE incidence between different catheter types revealed variations. The HD Mesh Ablator demonstrated the lowest incidence rate (15.1%), whereas the PVAC catheter had the highest (36.2%). The Farawave catheter had an incidence rate of 18.5% and showed no significant differences compared with most thermal catheters, except for the HD Mesh Ablator (relative risk, 0.15; 95% credible interval, 0.03-0.89). Our findings indicate that a substantial proportion of patients experience SCEs after catheter ablation for AF, with an overall incidence of approximately 19.1% occurring within 1 week (mostly within 72 hours) after ablation. No significant differences were observed in SCE incidence between pulsed field ablation and thermal ablation or between the Farawave catheter and most thermal catheters.
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Affiliation(s)
- Xianjin Hu
- Department of Cardiology, West China Hospital, Sichuan University, China
| | - Wenjie Li
- Department of Cardiology, West China Hospital, Sichuan University, China
| | - Bangjiaxin Ren
- Department of Cardiology, West China Hospital, Sichuan University, China
| | - Rui Zeng
- Department of Cardiology, West China Hospital, Sichuan University, China.
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Rozen G, Elbaz-Greener G, Andria N, Kevin Heist E, Ruskin JN, Roguin A, Carasso S, Birati E, Amir O, Marai I. Safety of Catheter Ablation for Atrial Fibrillation in Patients with Mechanical Prosthetic Valves. J Cardiovasc Electrophysiol 2022; 33:1128-1135. [PMID: 35304926 DOI: 10.1111/jce.15459] [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] [Received: 12/23/2021] [Revised: 03/03/2022] [Accepted: 03/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Catheter ablation (CA) for Atrial Fibrillation (AF) is increasingly utilized in the recent years, with promising results. We aimed to investigate the nationwide trends in utilization and procedural complications of CA for AF in patients with mechanical prosthetic valves (MPVs). METHODS AND RESULTS We drew data from the US National Inpatient Sample (NIS) database to identify cases of AF ablations in patients with MPVs, between 2003-2015. Sociodemographic and clinical data were collected, and incidence of procedural complications, mortality, and length of stay were analyzed. We compared the outcomes to a propensity matched cohort of patients without MPVs. The study included a weighted total of 1898 CA for AF cases in patients with MPVs. The median age of the study population was 67 (61-75) years and 53% were males. Despite the increasing age and significant uptrend in the prevalence of individual comorbidities and Deyo - Charlson Comorbidity Index (CCI) over the years, the risk of peri-procedural complications and mortality in the study group didn't change between the early (2003-2008) and late (2009-2015) study years. The peri-procedural complication rate (8.4% vs 10.4%, p=0.33) and in-hospital mortality (0.2% vs. 0.2%, p=0.9) did not differ significantly between patients with MPVs and 1901 matched patients without MPVs. Length of stay was higher among patients with prior MPVs compared to the controls (4.0±0.2 vs. 3.3±0.2 days, p=0.011). CONCLUSION This nationwide analysis shows that AF ablation in patients with mechanical valve prostheses bares similar risk of periprocedural complications and mortality as in patients without prosthetic valves. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Guy Rozen
- Cardiology Division, Hillel Yaffe Medical Center, Hadera, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.,Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gabby Elbaz-Greener
- Department of Cardiology, Hadassah Medical Center. The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nizar Andria
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and Surgery, Baruch Padeh Medical Center, Poriya, The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - E Kevin Heist
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ariel Roguin
- Cardiology Division, Hillel Yaffe Medical Center, Hadera, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Shemy Carasso
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and Surgery, Baruch Padeh Medical Center, Poriya, The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Edo Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and Surgery, Baruch Padeh Medical Center, Poriya, The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Offer Amir
- Department of Cardiology, Hadassah Medical Center. The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ibrahim Marai
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and Surgery, Baruch Padeh Medical Center, Poriya, The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
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Nakamura K, Sasaki T, Minami K, Take Y, Kimura K, Haraguchi Y, Sasaki W, Kishi S, Yoshimura S, Nakatani Y, Miki Y, Goto K, Kaseno K, Yamashita E, Koyama K, Funabashi N, Naito S. Symptomatic and asymptomatic intracerebral hemorrhages detected by magnetic resonance imaging after catheter ablation of atrial fibrillation. J Interv Card Electrophysiol 2021; 64:443-454. [PMID: 34432185 DOI: 10.1007/s10840-021-01051-6] [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] [Received: 06/02/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Symptomatic intracerebral hemorrhages (ICHs) are a rare complication after atrial fibrillation (AF) catheter ablation, while the incidence of asymptomatic ICHs detected by magnetic resonance (MR) imaging remains unclear. This study aimed to investigate the incidence, characteristics, and predictors of new-onset ICHs on MR imaging after AF ablation. METHODS We retrospectively studied 1257 consecutive AF ablation procedures in 1201 patients who underwent MR imaging on the day after the procedure. Repeat MR imaging within 3 months post-ablation was available in 352 procedures. RESULTS Old ICHs on the initial MR imaging were observed in 28 procedures (2.2%). Post-ablation new ICHs were observed in 14 procedures (4.0%), including one symptomatic (0.3%) and 13 (3.7%) asymptomatic ICHs. One patient had a new ICH on the initial MR imaging, while the remaining 13 had such on the repeat MR imaging. A univariate analysis revealed that a previous ischemic stroke or transient ischemic attack (TIA) and the CHA2DS2-VASc score were positive predictors of new ICHs (odds ratios, 5.502 and 1.435; P = 0.004 and 0.044). The lesion diameter did not significantly differ between the old and new ICHs (median, 6.1 mm vs. 8.0 mm, P = 0.281), while the predominant location differed (lobar areas, 22.6% vs. 53.3%; cerebellum, 22.6% vs. 20.0%; others, 54.8% vs. 26.7%; P = 0.026). CONCLUSIONS A few asymptomatic ICHs may occur after AF ablation. Most of the post-ablation new ICHs occurred a few days or later after the procedure. A previous ischemic stroke/TIA and the CHA2DS2-VASc score may be risk factors for post-ablation ICHs.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan.
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Koki Kimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Yumiko Haraguchi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Yosuke Nakatani
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, 260-8670, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
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Nakamura K, Sasaki T, Take Y, Minami K, Sasaki W, Kishi S, Yoshimura S, Okazaki Y, Miki Y, Goto K, Kaseno K, Yamashita E, Koyama K, Funabashi N, Naito S. Effect of preventing air intrusion on silent strokes during atrial fibrillation ablation using a mini-basket catheter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:71-81. [PMID: 33216388 DOI: 10.1111/pace.14131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/04/2020] [Accepted: 11/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Air bubble intrusion through transseptal sheaths during left atrial (LA) catheter ablation can cause cerebral embolisms, especially when using complex-shape catheters. This study aimed to compare the incidence of silent cerebral events (SCEs) after atrial fibrillation (AF) catheter ablation using a mini-basket catheter (IntellaMap Orion; Boston Scientific) between the following groups: group SP, strict prevention of LA air intrusion and group CP, conventional air intrusion prevention. METHODS We enrolled 123 consecutive AF patients (group SP, n = 61 and group CP, n = 62) who underwent brain magnetic resonance imaging after a local-impedance-guided ablation using one mini-basket catheter and one circular mapping catheter. The preventive strategy in group SP included (a) the insertion of the mini-basket catheter into the transseptal sheaths in a container filled with heparinized saline and (b) no exchange of all catheters over the sheaths. RESULTS SCEs were detected in 67 patients (54.5%), and the incidence of SCEs did not significantly differ between groups SP and CP (55.7% vs 53.2%; P = .780). A multivariate analysis demonstrated that an older age, non-paroxysmal AF, and radiofrequency (RF) power output were independent positive predictors of SCEs (odds ratios: 1.079, 5.613, and 1.405; P = .005, <.001, and .012). On the follow-up MR imaging, 83.5% of the SCEs in group SP and 87.7% in group CP disappeared (P = .398). CONCLUSIONS Strict prevention of LA air intrusion may have no additional effect for reducing the incidence of SCEs after local impedance-guided AF ablation using a mini-basket catheter. An older age, non-paroxysmal AF, and high-power RF applications may increase the risk of SCEs.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
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Nakamura K, Sasaki T, Take Y, Minami K, Inoue M, Asahina C, Sasaki W, Kishi S, Yoshimura S, Okazaki Y, Motoda H, Niijima K, Miki Y, Goto K, Kaseno K, Yamashita E, Koyama K, Funabashi N, Naito S. Incidence and characteristics of silent cerebral embolisms after radiofrequency-based atrial fibrillation ablation: A propensity score-matched analysis between different mapping catheters and indices for guiding ablation. J Cardiovasc Electrophysiol 2020; 32:16-26. [PMID: 33141496 DOI: 10.1111/jce.14800] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/24/2020] [Accepted: 09/22/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The difference in the incidence and characteristics of silent cerebral events (SCEs) after radiofrequency-based atrial fibrillation (AF) ablation between the different mapping catheters and indices used for guiding radiofrequency ablation remains unclear. This study aimed to compare the incidence and characteristics of postablation SCEs between the following two groups: Group C, Ablation Index-guided ablation using two circular mapping catheters with CARTO (Biosense Webster); Group R, local impedance-guided ablation using one mini-basket catheter and one circular mapping with Rhythmia (Boston Scientific). METHODS AND RESULTS Of 211 consecutive patients who underwent an AF ablation and brain magnetic resonance (MR) imaging after the ablation, 120 patients (each group, n = 60) were selected by propensity score matching. SCEs were detected in 37 patients (30.8%). Group R had a higher incidence of SCEs (51.7% vs. 10.0%; p < .001) and more SCEs per patient (median, 3 vs. 1, p = .028) than Group C. A multivariate analysis demonstrated that nonparoxysmal AF and being Group R were independent positive predictors of SCEs (odds ratios, 6.930 and 15.464; both p < .001). On the follow-up MR imaging, all SCEs in Group C and 87.9% of the SCEs in Group R disappeared (p = .537). CONCLUSIONS Group R had a significantly higher incidence of SCEs than Group C. Most probably the use of a complexly designed basket mapping catheter is the reason for the difference in the incidence of SCEs but further validation is needed. A nonparoxysmal form of AF may also increase the risk of SCEs during these ablation procedures.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Chisa Asahina
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Hiroyuki Motoda
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Katsura Niijima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
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Sun Y, Liu X, Xu Y. Meta-analysis of efficacy and safety of new oral anticoagulants compared with warfarin in Japanese patients undergoing catheter ablation for atrial fibrillation. J Interv Card Electrophysiol 2020; 58:381-399. [PMID: 32458179 DOI: 10.1007/s10840-020-00784-0] [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] [Received: 09/22/2019] [Accepted: 05/15/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This meta-analysis was designed to evaluate the efficacy and safety of new oral anticoagulants (NOACs) for perioperative anticoagulation of atrial fibrillation (AF) catheter ablation (CA) in Japanese patients with non-valvular atrial fibrillation (NVAF). METHODS PubMed, Embase, Web of Science, and the Cochrane Library were searched for articles published up to June 30, 2019. Two reviewers independently screened literature, extracted data, and assessed the methodological quality of the included studies according to the inclusion and exclusion criteria. Then, meta-analysis was performed using RevMan 5.3 software. RESULTS Nineteen studies with a total of 6827 patients were included in this meta-analysis. The experimental group received dabigatran, rivaroxaban, apixaban, or edoxaban; the control group received warfarin. The safety endpoints were bleeding complications; the efficacy endpoints were thromboembolic complications. Results were as follows: Patients with NOACs had a lower risk of overall bleeding complications (OR = 0.69, 95% CI (0.54, 0.87), P = 0.002), including major bleeding complications (OR = 0.52, 95% CI (0.32, 0.84), P = 0.007) and minor bleeding complications (OR = 0.73, 95% CI (0.56, 0.94), P = 0.02). There was no significant difference in thromboembolic complications between NOACs and warfarin after CA (OR = 0.39, 95% CI (0.14, 1.10), P = 0.08). CONCLUSIONS In Japanese NVAF patients undergoing CA, NOACs have similar effects to warfarin in the prevention of stroke and systemic embolism. Moreover, NOACs were associated with a lower incidence of bleeding complications.
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Affiliation(s)
- Yuchao Sun
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Nanjing Medical University, #261 Huansha Road, Shangcheng District, Hangzhou, 310000, Zhejiang Province, China
| | - Xiaohua Liu
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Nanjing Medical University, #261 Huansha Road, Shangcheng District, Hangzhou, 310000, Zhejiang Province, China
| | - Yizhou Xu
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Nanjing Medical University, #261 Huansha Road, Shangcheng District, Hangzhou, 310000, Zhejiang Province, China.
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Thromboembolism and bleeding risk in atrial fibrillation ablation with uninterrupted anticoagulation between new oral anticoagulants and vitamin K antagonists: insights from an updated meta-analysis. J Thromb Thrombolysis 2019; 50:201-210. [DOI: 10.1007/s11239-019-01989-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Yanagisawa S, Inden Y, Fujii A, Sakamoto Y, Tomomatsu T, Mamiya K, Okamoto H, Shibata R, Murohara T. Prothrombotic Responses After Catheter Ablation for Atrial Fibrillation During Uninterrupted Oral Anticoagulant Agent Administration. JACC Clin Electrophysiol 2019; 5:1418-1427. [PMID: 31857041 DOI: 10.1016/j.jacep.2019.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the extent of changes in prothrombotic responses after catheter ablation for atrial fibrillation (AF) under uninterrupted oral anticoagulant agent (OAC) administration. BACKGROUND Catheter ablation for AF has a potential risk for prothrombotic activation and silent thromboembolic events. METHODS A total of 814 patients (n = 172 [warfarin], n = 153 [dabigatran], n = 134 [rivaroxaban], and n = 301 [apixaban] patients undergoing AF ablation and a control group of 54 patients undergoing non-AF ablation) were included. Uninterrupted OACs were administered during the procedure in patients with AF. Blood samples were collected the day before and 3 days after the procedure. RESULTS At baseline, D-dimer levels were within normal limits (≤1.0 μg/ml) in more than 90% of the patients in all groups. However, after 3 days, this proportion decreased to 67%, 73%, 59%, 68%, and 65% in the warfarin, dabigatran, rivaroxaban, apixaban, and control groups, respectively (p = 0.180). Changes in prothrombin fragment 1+2 levels differed (p < 0.001), whereas fibrin monomer complex levels 3 days after ablation at a trough were equivalent within normal ranges among the groups (p = 0.146). Multivariate analysis revealed that age, CHA2DS2-VASc score, first session, and radiofrequency ablation were independent predictors of increased D-dimer levels after the procedure. Various changes in prothrombotic markers were observed between the warfarin and direct OAC groups after propensity score matching analyses. CONCLUSIONS The coagulation cascade was activated after catheter ablation for AF under uninterrupted OAC administration. The changes in various prothrombotic markers differed among the OAC groups.
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Affiliation(s)
- Satoshi Yanagisawa
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Aya Fujii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Sakamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshiro Tomomatsu
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keita Mamiya
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroya Okamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Rei Shibata
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Perioperative Safety and Efficacy of Different Anticoagulation Strategies With Direct Oral Anticoagulants in Pulmonary Vein Isolation: A Meta-Analysis. JACC Clin Electrophysiol 2019; 4:794-806. [PMID: 29929673 DOI: 10.1016/j.jacep.2018.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/11/2018] [Accepted: 04/19/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the safety and efficacy of uninterrupted and interrupted direct oral anticoagulant (DOAC) administration in patients undergoing pulmonary vein isolation (PVI). BACKGROUND The optimal periprocedural management of DOACs in patients undergoing PVI is not well defined, and different strategies are used. METHODS A systematic search of PubMed/MEDLINE, Ovid/MEDLINE, and EMBASE was performed. Three strategies for periprocedural DOAC administration were considered: uninterrupted, mildly interrupted (<12 h), and interrupted (≥12 h). Primary endpoints were major bleeding (MB) and thromboembolic (TE) complications; pooled weighted mean incidence (WMI) was calculated using a random-effects model. A secondary endpoint was the WMI of overall bleeding (OB). RESULTS The analysis included 43 studies for a total of 8,362 patients. DOACs showed similar safety and efficacy in the 3 subgroups. The WMI of MB was 1.02%, 1.49%, and 1.17% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively; the WMI of TE complications was 0.16%, 0.46%, and 0.49% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively, with no heterogeneity. OB appeared to be higher in uninterrupted (6.33%) and mildly interrupted (8.62%) groups compared with the interrupted (3.53%), with substantial heterogeneity among studies. No interaction was found between the incidence of MB and TE complications and different DOACs. CONCLUSIONS In patients undergoing PVI, these 3 anticoagulation strategies may have similar safety and efficacy in terms of MB and TE complications. OB appears to be higher in uninterrupted and mildly interrupted strategies compared with the interrupted strategy. No substantial differences were observed among DOACs regarding the incidence of MB and TE complications.
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10
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Nakamura K, Sasaki T, Take Y, Minami K, Inoue M, Kishi S, Yoshimura S, Sasaki W, Okazaki Y, Motoda H, Niijima K, Miki Y, Goto K, Yamashita E, Koyama K, Funabashi N, Naito S. Impact of the type of electroanatomic mapping system on the incidence of cerebral embolism after radiofrequency catheter ablation of left atrial tachycardias. Heart Rhythm 2019; 17:250-257. [PMID: 31518721 DOI: 10.1016/j.hrthm.2019.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Left atrial tachycardias (ATs) often occur after left atrial ablation. The incidence of symptomatic and silent cerebral embolism after radiofrequency catheter ablation of left ATs and the impact of the type of 3-dimensional electroanatomic mapping (3D-EAM) system on the incidence of cerebral embolism remain unclear. OBJECTIVES This study aimed to investigate the incidence of cerebral embolism after a 3D-EAM system-guided left AT ablation procedure and compare that between the different 3D-EAM systems. METHODS We prospectively enrolled 59 patients who underwent left AT ablation and brain magnetic resonance imaging after the procedure: 30 were guided by the Rhythmia system (Boston Scientific, Marlborough, MA) and 29 by the CARTO system (Biosense Webster, Diamond Bar, CA) (groups R and C, respectively). RESULTS One transient ischemic attack occurred in group R, and no symptomatic embolism occurred in group C. Silent cerebral ischemic lesions (SCILs) were observed in 35 patients (59.3%), and group R had a significantly higher incidence of SCILs than did group C (86.2% vs 33.3%; P < .001). In multivariate analysis, group R and left atrial linear ablation were independent positive predictors of SCILs (odds ratio 12.822 and 8.668; P = .001 and P = .005). The incidence of bleeding complications was comparable between groups R and C (0% vs 3.3%; P = .508). CONCLUSION Group R exhibited a higher incidence of postablation cerebral embolism than did group C. The use of the high-resolution 3D-EAM system with a mini-basket catheter to guide radiofrequency ablation of left atrial macroreentrant tachycardias may markedly increase the risk of silent cerebral embolism. The present results require further validation in a randomized study.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan.
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Hiroyuki Motoda
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Katsura Niijima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chuo-ku, Chiba City, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi City, Gunma, Japan
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11
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Osaka Y, Ono Y, Tao S, Goto K, Miyazaki T, Suzuki A, Kurihara K, Otomo K, Hirao K. Feasibility and safety of uninterrupted apixaban in patients undergoing radiofrequency ablation for atrial fibrillation. J Interv Card Electrophysiol 2019; 58:35-41. [DOI: 10.1007/s10840-019-00563-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
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12
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Ge Z, Faggioni M, Baber U, Sartori S, Sorrentino S, Farhan S, Chandrasekhar J, Vogel B, Qadeer A, Halperin J, Reddy V, Dukkipati S, Dangas G, Mehran R. Safety and efficacy of nonvitamin K antagonist oral anticoagulants during catheter ablation of atrial fibrillation: A systematic review and meta-analysis. Cardiovasc Ther 2018; 36:e12457. [PMID: 29971964 DOI: 10.1111/1755-5922.12457] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 12/13/2022] Open
Abstract
AIMS Catheter ablation for atrial fibrillation (AF) is associated with a transitory increase in the risk of both thromboembolic and bleeding events. Evidence on the use of nonvitamin K antagonist oral anticoagulants (NOACs) in patients undergoing AF ablation mostly comes from small observational studies, underpowered to detect differences in clinical outcomes between NOACs and vitamin K antagonists (VKAs) treated patients. This updated meta-analysis aimed to determine the safety and efficacy of periprocedural anticoagulation with NOACs compared with VKAs in AF patients undergoing catheter ablation. METHODS We searched MEDLINE, Cochrane library, and web sources for randomized and observational studies comparing periprocedural treatment with NOACs and VKAs in patients undergoing AF ablation. The primary safety endpoint was major bleeding events, and the primary efficacy endpoint was thromboembolic events (a composite of systemic thromboembolism, transient ischemic attack, and stroke). RESULTS A total of 29 studies with 12 644 patients were included in the meta-analysis. Overall, patients on NOACs had a significantly lower risk of major bleeding compared to VKAs either in observational studies (Peto OR 0.68; 95% CI: 0.48-0.95; P = 0.022; I2 = 20%) or in RCTs (Peto OR 0.30; 95% CI: 0.14-0.62; P = 0.001; I2 = 28%). Uninterrupted NOACs reduced the risk of major bleeding when compared to uninterrupted VKAs (Peto OR 0.66; 95% CI: 0.45-0.96; P = 0.028; I2 = 1%), similarly, interrupted NOACs lowered the risk of major bleeding compared to interrupted VKAs (Peto OR 0.29; 95% CI: 0.13-0.66; P = 0.003; I2 = 0%; Pinteraction = 0.076). The rate of thromboembolic complications was very low and did not significantly differ between the study groups either in observational studies (Peto OR 0.91; 95% CI: 0.49-1.67; P = 0.755; I2 = 0%) or in RCTs (Peto OR 0.14; 95% CI: 0.01-1.30; P = 0.083; I2 = 0%). CONCLUSIONS Use of NOACs compared to VKAs significantly reduced the risk of bleeding in patients with AF ablation. Similarly, the risk of bleeding was lower with uninterrupted NOACs than with uninterrupted VKAs, and with interrupted NOACs than with interrupted VKAs. The rate of thromboembolic complications was extremely low in both study groups without any differences.
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Affiliation(s)
- Zhen Ge
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York.,Division of cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Michela Faggioni
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Samantha Sartori
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Sabato Sorrentino
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Serdar Farhan
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Jaya Chandrasekhar
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Birgit Vogel
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Abdul Qadeer
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Jonathan Halperin
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Vivek Reddy
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Srinivas Dukkipati
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - George Dangas
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute, New York, New York
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13
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Continuous and minimally-interrupted direct oral anticoagulant are both safe compared with vitamin K antagonist for atrial fibrillation ablation: An updated meta-analysis. Int J Cardiol 2018; 262:51-56. [DOI: 10.1016/j.ijcard.2018.03.095] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/07/2018] [Accepted: 03/19/2018] [Indexed: 11/21/2022]
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14
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Nakamura K, Naito S, Sasaki T, Take Y, Minami K, Kitagawa Y, Motoda H, Inoue M, Otsuka Y, Niijima K, Yamashita E, Sugai Y, Kumagai K, Koyama K, Funabashi N, Oshima S. Uninterrupted vs. interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: a prospective randomized single-centre study on post-ablation thrombo-embolic and haemorrhagic events. Europace 2018; 21:259-267. [DOI: 10.1093/europace/euy148] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/31/2018] [Indexed: 02/01/2023] Open
Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Yoshiyuki Kitagawa
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Hiroyuki Motoda
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Yoshimitsu Otsuka
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Katsura Niijima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Yoshinao Sugai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Koji Kumagai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, Japan
| | - Shigeru Oshima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, Japan
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15
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Rahman H, Khan SU, DePersis M, Hammad T, Nasir F, Kaluski E. Meta-analysis of safety and efficacy of oral anticoagulants in patients requiring catheter ablation for atrial fibrillation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:147-152. [PMID: 29786530 DOI: 10.1016/j.carrev.2018.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/04/2018] [Accepted: 05/04/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND The ideal oral anticoagulant agent during catheter ablation (CA) for atrial fibrillation (AF) remained unclear. HYPOTHESIS Novel oral anticoagulants (NOACs) are safer and effective compared to uninterrupted vitamin K antagonists (U-VKA) among patients requiring CA for AF. METHODS Four randomized controlled trials (RCTs) and 9 observational studies (OS) were selected using PubMed/Medline, EMBASE and the CENTRAL data bases (Inception-December-2017). Estimates were reported as random effects risk ratio (RR) with 95% confidence interval (CI). The primary safety outcome was major bleeding and main efficacy endpoint was thromboembolism. RESULTS In RCTs restricted analysis, NOACs significantly reduced the relative risk of major bleeding by 72% compared to U-VKA (RR, 0.28, 95% CI, 0.14-0.58, P < 0.001). This significant effect was not achieved in OS based analysis (RR, 0.86, 95% CI, 0.42-1.78, P = 0.68). In terms of thromboembolism, both anticoagulation strategies were equally effective in analysis of RCTs (RR, 0.28, 95% CI, 0.05-1.70, P = 0.17) or OS (RR, 1.43, 95% CI, 0.46-4.39, P = 0.54). In sensitivity analysis, there was no difference among uninterrupted NOACs (U-NOACs) and U-VKA in terms of major bleeding [(RCTs: RR, 0.33, 95% CI, 0.10-1.06, P = 0.06); (OS: RR, 0.70, 95% CI, 0.28-1.78, P = 0.46)] or thromboembolism [(RCTs: RR, 0.25, 95% CI, 0.03-2.29, P = 0.22); (OS: RR, 0.68, 95% CI, 0.08-5.53, P = 0.72)]. CONCLUSION NOACs, either interrupted or un-interrupted, are safer and equally effective drugs compared to U-VKA in AF patients requiring CA.
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Affiliation(s)
- Hammad Rahman
- Guthrie Health System/ Robert Packer Hospital, Sayre, PA, USA.
| | - Safi U Khan
- Guthrie Health System/ Robert Packer Hospital, Sayre, PA, USA
| | | | | | - Fahad Nasir
- Guthrie Health System/ Robert Packer Hospital, Sayre, PA, USA
| | - Edo Kaluski
- Guthrie Health System/ Robert Packer Hospital, Sayre, PA, USA; Rutgers New Jersey Medical School, Newark, NJ, USA; The Geisinger Commonwealth Medical College, Scranton, PA, USA
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16
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Xing Y, Xu B, Sheng X, Xu C, Peng F, Sun Y, Wang S, Guo H. Efficacy and safety of uninterrupted low-intensity warfarin for cryoballoon ablation of atrial fibrillation in the elderly: A pilot study. J Clin Pharm Ther 2018; 43:401-407. [PMID: 29484682 DOI: 10.1111/jcpt.12671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 01/18/2018] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Uninterrupted warfarin during cryoballoon ablation (CB-A) of atrial fibrillation (AF) has been widely accepted. However, to our knowledge, no previous studies exist investigating the optimal intensity of anticoagulation with warfarin for CB-A. This study aimed to evaluate the efficacy and safety of uninterrupted low-intensity warfarin for CB-A of AF in the elderly. METHODS Paroxysmal AF patients (age ≥ 70 years) who underwent CB-A were enrolled prospectively. The participants were stratified into 2 groups based on international normalized ratio (INR) before ablation (INR in group A: 1.5 to 2.0; INR in group B: 2.0-2.5). Primary endpoints included periprocedural thromboembolic complications and major bleeding. Secondary endpoints were new asymptomatic cerebral emboli (ACE) and minor bleeding. RESULTS AND DISCUSSION A total of 144 patients were enrolled (group A: 65; group B: 79). In group A, the use of concomitant antiplatelet drugs was more common. Also, the mean HAS-BLED score was significantly higher (2.4 ± 0.8 vs 2.0 ± 0.6, P < .01) and the mean activated clotting time (ACT) during the procedure was significantly lower (302 ± 14 s vs 311 ± 11 s, P < .01). Other clinical characteristics were balanced between the 2 groups. No thromboembolic complications and major bleeding occurred in either group. The incidence of periprocedural ACE was comparable between the 2 groups (9.2% vs 6.3%, P = .74). The incidence of minor bleeding in group A and group B was 4.6% and 11.4%, respectively (P = .14). WHAT IS NEW AND CONCLUSION Compared with standard-intensity warfarin, uninterrupted low-intensity warfarin might not increase the incidence of thromboembolic complications and might be associated with less bleeding risk during the perioperative period of cryoballoon ablation in the elderly. Large trials are needed to confirm these results.
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Affiliation(s)
- Y Xing
- Department of Cardiology, Shaoxing People's Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
| | - B Xu
- Department of Cardiology, Shaoxing People's Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
| | - X Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
| | - C Xu
- Department of Cardiology, Shaoxing People's Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
| | - F Peng
- Department of Cardiology, Shaoxing People's Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
| | - Y Sun
- Department of Cardiology, Shaoxing People's Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
| | - S Wang
- Department of Cardiology, Shaoxing People's Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
| | - H Guo
- Department of Cardiology, Shaoxing People's Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
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17
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Cardoso R, Knijnik L, Bhonsale A, Miller J, Nasi G, Rivera M, Blumer V, Calkins H. An updated meta-analysis of novel oral anticoagulants versus vitamin K antagonists for uninterrupted anticoagulation in atrial fibrillation catheter ablation. Heart Rhythm 2018; 15:107-115. [DOI: 10.1016/j.hrthm.2017.09.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Indexed: 01/21/2023]
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18
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Elgendy AY, Mahtta D, Barakat AF, Abuzaid A, Mahmoud A, Mentias A, Mahmoud AN, Elgendy IY. Meta-Analysis of Safety and Efficacy of Uninterrupted Non-Vitamin K Antagonist Oral Anticoagulants Versus Vitamin K Antagonists for Catheter Ablation of Atrial Fibrillation. Am J Cardiol 2017; 120:1830-1836. [PMID: 28882334 DOI: 10.1016/j.amjcard.2017.07.096] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/13/2017] [Accepted: 07/20/2017] [Indexed: 12/26/2022]
Abstract
This meta-analysis sought to assess the safety and efficacy of uninterrupted non-vitamin K antagonist oral anticoagulants (NOACs) versus uninterrupted vitamin K antagonists in atrial fibrillation (AF) patients undergoing catheter ablation. Electronic databases were searched for randomized trials (RCTs) and observational studies that compared uninterrupted NOACs versus uninterrupted vitamin K antagonists in the catheter ablation of AF. Safety outcomes included major bleeding, total bleeding, minor bleeding, and cardiac tamponade. Efficacy outcomes were symptomatic thromboembolism and symptomatic stroke/transient ischemic attack. Summary estimate risk ratios (RRs) were constructed primarily with a DerSimonian-Laird model. Thirteen studies (3 RCTs and 10 observational studies) with 4,878 patients were included. The risk of major bleeding (RR 0.83, 95% confidence interval [CI] 0.46 to 1.50, p = 0.53), total bleeding (RR 0.90, 95% CI 0.71 to 1.15, p = 0.41), minor bleeding (RR 0.98, 95% CI 0.80 to 1.21, p = 0.85), cardiac tamponade (RR 0.85, 95% CI 0.43 to 1.69, p = 0.65), symptomatic thromboembolism (RR 0.92, 95% CI 0.26 to 3.31, p = 0.90), and symptomatic stroke/transient ischemic attack (RR 1.03, 95% CI 0.29 to 3.65, p = 0.97) was similar in both groups. The quality of evidence for both major bleeding and symptomatic thromboembolism was moderate for RCTs and very low for observational studies. In conclusion, the use of uninterrupted NOACs in AF catheter ablation appears to be safe and efficacious. The evidence is not of high quality; thus, further high-quality RCTs are needed to confirm these findings.
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Affiliation(s)
- Akram Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida.
| | - Dhruv Mahtta
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Amr F Barakat
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Ahmed Abuzaid
- Department of Cardiovascular Medicine, Sidney Kimmel Medical Collage at Thomas Jefferson University/Christiana Care Health System, Newark, Delaware
| | - Ahmad Mahmoud
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Amgad Mentias
- Division of Cardiovascular Medicine, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Ahmed N Mahmoud
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
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19
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Vlachos K, Efremidis M, Bazoukis G, Letsas KP, Saplaouras A, Georgopoulos S, Karamichalakis N, Rokiza A, Sakellaropoulou A, Kolokathis AM, Efremidis T, Asvestas D, Sideris A. Safety and efficacy of DOACs vs acenocoumarol in patients undergoing catheter ablation of atrial fibrillation. Clin Cardiol 2017; 40:847-852. [PMID: 28561951 PMCID: PMC6490606 DOI: 10.1002/clc.22734] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/26/2017] [Accepted: 05/01/2017] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Thromboembolic complications can be life-threatening during atrial fibrillation (AF) catheter ablation. The aim of our study was to evaluate the safety and efficacy of continuous treatment using direct oral anticoagulants (DOACs) as an alternative to uninterrupted acenocoumarol for periprocedural anticoagulation. HYPOTHESIS Continuous treatment with DOACs has similar safety and efficacy compared to acenocoumarol. METHODS We enrolled 474 patients (mean age, 58 years; 68.4% male) undergoing AF catheter ablation between June 2013 and December 2016. All patients were equally assigned to take acenocoumarol (group 1, 136 patients) or DOACs (group 2, 338 patients) for ≥2 months before the procedure. We compared thromboembolic and bleeding complications between the 2 groups. RESULTS Our analysis showed no significant difference in major and minor complications between the 2 patient groups. Specifically, 3 of 136 patients (2.2%) using uninterrupted acenocoumarol had a major complication (1 patient [0.7%] had transient ischemic attack resolved 8 hours later, 1 [0.7%] had pericardial tamponade, and 1 [0.7%] had a subcapsular renal hematoma) and 2 patients (1.4%) had minor complications (1 [0.7%] pseudoaneurysm and 1 [0.7%] groin hematoma). In group 2, 1 of 338 patients (0.3%) had a major complication (transient ischemic attack). In the same group, 7 patients (2.1%) had a minor complication (1 patient [0.3%] presented with pseudoaneurysm, 4 [1.2%] with pericardial effusion <1 cm, 1 [0.3%] femoral arteriovenous fistula between the femoral artery and femoral vein, and 1 [0.7%] groin hematoma). CONCLUSIONS DOACs and acenocoumarol have similar safety and effectiveness regarding thromboembolic complications prevention without increasing bleeding complications.
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Affiliation(s)
- Konstantinos Vlachos
- Laboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensGreece
| | - Michael Efremidis
- Laboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensGreece
| | - George Bazoukis
- Laboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensGreece
| | | | - Athanasios Saplaouras
- Laboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensGreece
| | - Stamatis Georgopoulos
- Laboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensGreece
| | | | - Aikaterini Rokiza
- Laboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensGreece
| | | | | | - Theodoros Efremidis
- Laboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensGreece
| | - Dimitrios Asvestas
- Laboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensGreece
| | - Antonios Sideris
- Laboratory of Cardiac Electrophysiology“Evangelismos” General Hospital of AthensGreece
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