Uninterrupted Dabigatran as Safe as Warfarin During AF Ablation

Summary and Comment |
March 19, 2017

Uninterrupted Dabigatran as Safe as Warfarin During AF Ablation

  1. Mark S. Link, MD

Fears of major bleeding during catheter ablation of atrial fibrillation with uninterrupted direct-acting oral anticoagulants may be unwarranted.

  1. Mark S. Link, MD

As prevalence of atrial fibrillation (AF) and its risk factors rises, the number of individuals undergoing catheter ablation of AF, already one of the most frequently performed procedures in the electrophysiology laboratory, is likely to increase. Anticoagulation during AF ablation must be aggressive enough to mitigate the risk for stroke but controllable enough to limit the risk for major bleeding events such as pericardial tamponade. Research has shown that uninterrupted warfarin use during AF ablation is actually safer than discontinuing warfarin and using a heparin bridge for the procedure. However, data are lacking on the safety of uninterrupted direct-acting oral anticoagulants during AF ablation, and the fear of bleeding complications is heightened by the absence of reversal agents for most of these drugs.

In an international, manufacturer-sponsored, randomized trial (NCT02348723), investigators compared uninterrupted dabigatran with uninterrupted warfarin in 635 patients undergoing AF ablation. The primary endpoint of major bleeding around the time of the procedure and up to 8 weeks later occurred in significantly fewer dabigatran recipients (5; 1.6%) than warfarin recipients (22; 6.9%). The rate of the secondary endpoint of thromboembolic events did not differ between the two groups (only 1 occurred, in the warfarin group).

Comment

As an AF ablater, I fear both pericardial tamponade and stroke. These findings demonstrate that uninterrupted dabigatran is at least as effective as uninterrupted warfarin, if not more effective, in reducing the risk for both. My practice will change as a result of this study: I am now more likely to continue direct-acting oral anticoagulants at least through the day before ablation, whereas before I withheld them for 24 hours.

Editor Disclosures at Time of Publication

  • Disclosures for Mark S. Link, MD at time of publication Grant / Research support Unequal Technologies Editorial boards UpToDate; Heart Rhythm Leadership positions in professional societies Heart Rhythm Society (Chair, CME Compliance Committee); American Heart Association (Chair, ACLS Writing Group; Member, Emergency Cardiovascular Care)

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