ABSTRACT
FUNDAMENTO: O manejo ideal da anticoagulação oral (ACO) no período pré- e pós-ablação de fibrilação atrial (FA) ainda é motivo de controvérsia. OBJETIVO: Comparar duas estratégias de anticoagulação: suspensão da warfarina com a utilização de heparina de baixo peso molecular (HBPM) e a realização da ablação sem a suspensão da warfarina, mantendo o RNI terapêutico (entre 2,0 e 3,0). MÉTODOS: 140 pacientes (pt) portadores de FA persistente/ permanente submetidos à ablação por cateter de FA foram divididos em dois grupos: no grupo I (70 pt), a warfarina foi suspensa cinco dias antes do procedimento e utilizada terapia de transição com HBPM (enoxaparina 1 mg/kg 2x/dia pré-ablação e 0,5 mg/kg 2x/dia após o procedimento); no grupo II (70 pt), a warfarina não foi suspensa e o procedimento foi realizado com RNI terapêutico. Ambos os grupos receberam heparina intravenosa (TCA > 350 seg) durante o procedimento. RESULTADOS: No Grupo I, observou-se complicação hemorrágica maior (1,4 por cento) e 4 pt (5,7 por cento) com complicações hemorrágicas menores. No Grupo II, 2 pt (2,8 por cento) apresentaram complicações hemorrágicas menores e 1 pt apresentou sangramento maior; porém, este ocorreu após uso de HBPM por RNI < 2,0. Não houve complicação tromboembólica ou morte cardiovascular nos dois grupos após 16 ± 8 meses. CONCLUSÃO: A realização de ablação por cateter de FA sem a suspensão de ACO e RNI terapêutico é uma estratégia semelhante em segurança e eficácia quando comparada à tradicional transição com HBPM, evitando um período inicial pós-ablação de anticoagulação potencialmente inadequada.
BACKGROUND: The ideal management of oral anticoagulation (OAC) before and after catheter ablation for atrial fibrillation (AF) is still controversial. OBJECTIVE: To compare two anticoagulation strategies for catheter ablation for AF: warfarin withholding and use of low-molecular-weight heparin (LMWH); and maintenance of warfarin and therapeutic INR (between 2.0 and 3.0). METHODS: 140 patients (pt) with persistent/permanent AF undergoing catheter ablation for AF were divided into two groups: Group I (70 pt), in which warfarin was withheld five days prior to the procedure and transition to LMWH was used (enoxaparin: 1 mg/kg 2x/day before ablation, and 0.5 mg/kg 2x/day after ablation); Group II (70 pt), in which warfarin was not withheld and the procedure was performed with therapeutic INR. Both groups received intravenous heparin (ACT > 350 seconds) during ablation. RESULTS: In Group I, one pt (1.4 percent) had a major hemorrhagic complication and four pts (5.7 percent) had minor hemorrhagic complications. In Group II, two pts (2.8 percent) had minor hemorrhagic complications and one pt had a major bleeding, which occurred after using LMWH due to INR < 2.0. None of the groups had thromboembolic complications or cardiovascular death over a period of 16 ± 8 months. CONCLUSION: Catheter ablation for AF without withholding OAC and with therapeutic INR is a strategy that has similar safety and efficacy when compared with the traditional transition to LMWH, avoiding the potentially inadequate anticoagulation of the initial post-ablation period.
Subject(s)
Aged , Female , Humans , Male , Anticoagulants/administration & dosage , Atrial Fibrillation/surgery , Hemorrhage/epidemiology , Heparin, Low-Molecular-Weight/administration & dosage , Preoperative Care/methods , Warfarin/administration & dosage , Anticoagulants/adverse effects , Atrial Fibrillation/blood , Atrial Fibrillation/drug therapy , Catheter Ablation , Chi-Square Distribution , Dose-Response Relationship, Drug , Hemorrhage/blood , Hemorrhage/chemically induced , Hemorrhage/prevention & control , Heparin, Low-Molecular-Weight/adverse effects , International Normalized Ratio , Postoperative Complications/prevention & control , Preoperative Care/adverse effectsABSTRACT
BACKGROUND: Long-term cessation of oral anticoagulation (OAC) after catheter ablation of atrial fibrillation (AF) has been deemed controversial. The safety of this management strategy in patients without recurrent AF and with historically elevated risks for thromboembolism remains largely unknown. In this study, we sought to evaluate the long-term results of OAC cessation after successful catheter ablation of AF. METHODS AND RESULTS: OAC and antiarrhythmic drugs (AADs) were discontinued irrespective of AF type or baseline CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack) risk score in 327 patients (mean age, 63±13 years; 79% men) with drug-refractory AF after catheter ablation (mean CHADS(2) score, 1.89±0.95; median, 2.0). Patients with a CHADS(2) score of 2 (45.4%) and 3 (23.2%) accounted for 68.8% of this cohort. In patients with a high risk of recurrence or prior thromboembolic complications, OAC was continued for up to 6 to 12 months postablation and antiplatelet therapy was administered to all patients who maintained sinus rhythm upon OAC interruption. After a follow-up of 46±17 months (range, 13-82 months), 82% remained AF free (off AADs). Significant predictors of late AF recurrence (P<0.05) were nonparoxysmal AF (hazard ration [HR], 1.83), female sex (HR, 2.19), age ≥60 years (HR, 1.81), left atrial size >40 mm (HR, 3.52), CHADS(2) score ≥2 (HR, 1.81), and early recurrences (HR, 5.52). No symptomatic ischemic cerebrovascular events were detected during follow-up despite interruption of OAC in 298 (91%) patients and AADs in 293 (89%) patients. CONCLUSIONS: No significant thromboembolic-related morbidity is observed when AADs and OAC are discontinued after successful catheter ablation of AF in patients with a CHADS(2) score ≤3 who are maintained on antiplatelet therapy during long-term follow-up.
Subject(s)
Anticoagulants/therapeutic use , Atrial Fibrillation/surgery , Catheter Ablation , Thromboembolism/epidemiology , Thromboembolism/prevention & control , Aged , Female , Follow-Up Studies , Humans , Longitudinal Studies , Male , Middle Aged , Risk Assessment , Time Factors , Treatment Outcome , Withholding TreatmentABSTRACT
BACKGROUND: The ideal management of oral anticoagulation (OAC) before and after catheter ablation for atrial fibrillation (AF) is still controversial. OBJECTIVE: To compare two anticoagulation strategies for catheter ablation for AF: warfarin withholding and use of low-molecular-weight heparin (LMWH); and maintenance of warfarin and therapeutic INR (between 2.0 and 3.0). METHODS: 140 patients (pt) with persistent/permanent AF undergoing catheter ablation for AF were divided into two groups: Group I (70 pt), in which warfarin was withheld five days prior to the procedure and transition to LMWH was used (enoxaparin: 1 mg/kg 2x/day before ablation, and 0.5 mg/kg 2x/day after ablation); Group II (70 pt), in which warfarin was not withheld and the procedure was performed with therapeutic INR. Both groups received intravenous heparin (ACT > 350 seconds) during ablation. RESULTS: In Group I, one pt (1.4%) had a major hemorrhagic complication and four pts (5.7%) had minor hemorrhagic complications. In Group II, two pts (2.8%) had minor hemorrhagic complications and one pt had a major bleeding, which occurred after using LMWH due to INR < 2.0. None of the groups had thromboembolic complications or cardiovascular death over a period of 16 ± 8 months. CONCLUSION: Catheter ablation for AF without withholding OAC and with therapeutic INR is a strategy that has similar safety and efficacy when compared with the traditional transition to LMWH, avoiding the potentially inadequate anticoagulation of the initial post-ablation period.
