Higher initial weight-based heparin dosing is required with direct oral anticoagulants during catheter ablation for atrial fibrillation.

BACKGROUND: Heparin dosing of patients anticoagulated with direct oral anticoagulants (DOACs) undergoing atrial fibrillation (AF) ablation can be challenging as they require more heparin than those on warfarin therapy. We sought to compare periprocedural activated clotting times (ACTs) of patients on warfarin vs. DOAC and determine an optimal weight-based heparin dosage strategy. METHODS: Patients who underwent AF ablation over 28 months were reviewed for type of anticoagulation, intraprocedural heparin dosing, ACTs, and adverse outcomes. A heparin dosing strategy was then tested in a prospective validation cohort. RESULTS: There were 89 patients in the DOAC group and 43 in the warfarin group. Demographics, comorbidities, and complication rates were similar. Mean ACT and percentage of therapeutic ACTs were lower in the DOAC group, most significantly in those with a weight > 90 kg. In DOAC patients, a higher initial heparin bolus ≥ 150 units/kg yielded a higher percentage of therapeutic intraprocedural ACTs (49% ± 10 vs. 29% ± 7, p = 0.0008). In a prospective validation cohort of 25 patients administered an initial heparin bolus ≥ 150 units/kg, the mean ACT was 295 ± 33 and 49% of the ACTs collected were therapeutic, similar to findings of our high-dose retrospective subgroup. CONCLUSION: Patients on DOACs require more heparin during AF ablation to achieve therapeutic ACT. We suggest an initial heparin dose of at least 150 units/kg in this subset of patients, particularly in those with a weight > 90 kg.

Heparin reversal with protamine sulfate is not required in atrial fibrillation ablation with suture hemostasis.

BACKGROUND: The utility of protamine sulfate for heparin reversal in catheter-based atrial fibrillation (AF) ablation is unclear when using the suture closure technique for vascular hemostasis. OBJECTIVE: This study sought to address if protamine sulfate use for heparin reversal reduces vascular access complications in AF catheter ablation when suture techniques are used for postprocedural vascular hemostasis. METHODS: This is a retrospective multicenter observational study of 294 consecutive patients who underwent catheter ablation for AF with subsequent vascular access hemostasis by means of a figure-of-eight suture or stopcock technique. A total of 156 patients received protamine for heparin reversal before sheath removal while 138 patients did not receive protamine. The two groups were compared for procedural activated clotting time (ACT), access site complications, and duration of hospital stay. RESULTS: Baseline demographic characteristics were comparable in both groups. Despite higher ACT before venous sheath removal in patients not receiving protamine (288.0 ± 44.3 vs 153.9 ± 32.0 seconds; P < .001), there was no significant difference in groin complications, postoperative thromboembolic events, or duration of hospital stay between the two groups. Suture failure requiring manual compression was rarely observed in this cohort (0.34%). CONCLUSION: With modern vascular access and sheath management techniques, for patients undergoing catheter ablation for AF, simple suture closure techniques can obviate the need for protamine administration to safely achieve hemostasis after removal of vascular sheaths.

Figure-of-eight sutures for hemostasis result in shorter lab recovery time after ablation for atrial fibrillation.

BACKGROUND: Ablation for atrial fibrillation (AF) requires multiple venous sheaths and anticoagulation with heparin, both risk factors for bleeding complications. Manual compression (MC) with heparin reversal is the standard method to achieve venous hemostasis postablation; however, temporary figure-of-eight sutures (F8S) are an alternative. While this technique has been shown to be safe and effective, little is known about its effect on postprocedural recovery time. METHODS: In this retrospective cohort study, consecutive patients who underwent AF radiofrequency ablation over a 23-month period were reviewed for type of hemostasis (manual compression or figure-of-eight suture), demographics, periprocedural anticoagulation, groin complications, and procedural duration. RESULTS: A total of 104 patients were included (42 in the MC group and 62 in the F8S group). The two groups were similar for mean age, gender, weight, oral anticoagulant use, and procedural heparin dosing. Access site complications were 4.76% versus 3.23% (P = 0.68). Time from procedure end to sheath removal was lower in the F8S group (16.2 ± 8.47 vs 4.25 ± 4.14 min, P < 0.0001). Overall time from procedure end to hemostasis was 36.1 ± 10.1 min in the MC group versus 7.9 ± 5.6 in the F8S group (P < 0.0001). Times to extubation and transport out of the lab were both significantly lower in the F8S group (34.1 ± 14.6 vs 13.5 ± 5.4 min, and 44 ± 14.6 vs 21.9 ± 6.7 min, respectively, P < 0.0001). CONCLUSION: Figure-of-eight sutures provided efficient hemostasis following AF ablation, with significantly reduced postprocedure recovery time including time to hemostasis, extubation, and transport out of the lab.