Early Experience of Novel Oral Anticoagulants in Catheter Ablation for Atrial Fibrillation: Efficacy and Safety Comparison to Warfarin

Increased bleeding events with the addition of apixaban to the dual anti-platelet regimen for the treatment of patients with acute coronary syndrome: A meta-analysis

BACKGROUND

Dual anti-platelet therapy (DAPT) with aspirin and clopidogrel has been the mainstay of treatment for patients with acute coronary syndrome (ACS). However, the recurrence of thrombotic events, potential aspirin and clopidogrel hypo-responsiveness, and other limitations of DAPT have led to the development of newer oral anti-thrombotic drugs. Apixaban, a new non-vitamin K antagonist, has been approved for use. In this meta-analysis, we aimed to compare the bleeding outcomes observed with the addition of apixaban to DAPT for the treatment of patients with ACS.

METHODS

Online databases including EMBASE, Cochrane Central, http://www.ClinicalTrials.gov, MEDLINE and Web of Science were searched for English based publications comparing the use of apixaban added to DAPT for the treatment of patients with ACS. Different categories of bleeding events and cardiovascular outcomes were assessed. The analysis was carried out by the RevMan software version 5.4. Odds ratios (OR) with 95% confidence intervals (CI) were used to represent the data following analysis.

RESULTS

This research analysis consisted of 4 trials with a total number of 9010 participants. Thrombolysis in myocardial infarction (TIMI) defined major bleeding (OR: 2.45, 95% CI: 1.45-4.12; P = .0008), TIMI defined minor bleeding (OR: 3.12, 95% CI: 1.71-5.70; P = .0002), International society of thrombosis and hemostasis (ISTH) major bleeding (OR: 2.49, 95% CI: 1.80-3.45; P = .00001) and Global Use of Strategies to Open Occluded Arteries (GUSTO) defined severe bleeding (OR: 3.00, 95% CI: 1.56-5.78; P = .01) were significantly increased with the addition of apixaban to DAPT versus DAPT alone in these patients with ACS. However fatal bleeding (OR: 10.96, 95% CI: 0.61-198.3; P = .11) was not significantly different.

CONCLUSIONS

Addition of the novel oral anticoagulant apixaban to the DAPT regimen significantly increased bleeding and therefore did not show any beneficial effect in these patients with ACS. However, due to the extremely limited data, we apparently have to rely on future larger studies to confirm this hypothesis.

Meta-analysis of the safety and efficacy of using minimally interrupted novel oral anticoagulants in patients undergoing catheter ablation for atrial fibrillation

PURPOSE

The ideal periprocedural anticoagulation strategy for patients being treated with a novel oral anticoagulant (NOAC) during catheter ablation (CA) for atrial fibrillation (AF) is unclear. We evaluated the safety and efficacy of using a minimally interrupted NOAC strategy versus an uninterrupted NOAC or vitamin K antagonist (VKA) strategy during AF ablation.

METHODS

The Cochrane Library, PubMed, and EMBASE databases were searched for randomized controlled or prospective observational studies that compared a minimally interrupted NOAC strategy with an uninterrupted NOAC or VKA strategy from the time of database establishment up to December 2019. The primary endpoints were major bleeding, minor bleeding, and symptomatic thromboembolism. The secondary endpoint was silent cerebral infarction (SCI) as detected by post-ablation brain magnetic resonance imaging (MRI). A measurement of treatment effect for the endpoint was reported as pooled odds ratio (OR) with 95% confidence interval (CI).

RESULTS

A total of 18 studies (6 randomized, 11 observational, and 1 randomized registry) with 6203 patients were included in the final analysis (47% of the patients received minimally interrupted NOAC). There was no significant difference between treatment groups regarding the risk for major bleeding (OR 1.04, 95% CI 0.69-1.57, P = 0.86, I² = 27%). Different stratification methods did not yield significant difference regarding the risk for major bleeding. There was no difference between groups regarding the risk for minor bleeding (P = 1.00) or symptomatic thromboembolism (P = 0.26). Brain MRI results showed that both uninterrupted NOAC (OR 0.44, 95% CI 0.23-0.83, P = 0.01, I² = 72%) and uninterrupted VKA (OR 0.48, 95% CI 0.24-0.97, P = 0.04, I² = 36%) produced a significant reduction in the rate of SCI when compared with minimally interrupted NOAC.

CONCLUSIONS

A periprocedural anticoagulation strategy of minimally interrupted NOAC is not superior to uninterrupted NOAC or VKA when used during AF ablation. There is evidence favoring the use of uninterrupted NOAC or VKA in terms of the risk for SCI.

Unilateral versus Bilateral Groin Puncture for Atrial Fibrillation Ablation: Multi-Center Prospective Randomized Study

PURPOSE

Catheter ablation for atrial fibrillation (AF) requires heavy anticoagulation and uncomfortable post-procedural hemostasis. We compared patient satisfaction with and the safety of unilateral groin (UG) puncture-single trans-septal (ST) ablation with conventional bilateral groin (BG) puncture-double trans-septal (DT) ablation in paroxysmal AF patients.

MATERIALS AND METHODS

We enrolled 222 patients with paroxysmal AF (59.4±10.7 years old) who were randomized in a 2:1 manner into UG-ST ablation (n=148) and BG-DT ablation (n=74) groups. If circumferential pulmonary vein isolation could not be achieved after three attempts of touch-up ablation in the UG-ST group, the patient was crossed over to BG-DT by performing a left groin puncture.

RESULTS

Ten patients in the UG-ST group (6.8%) required crossover to the BG-DT approach. There were no significant differences in procedure time (p=0.144) and major complications rate (p>0.999) between the UG-ST and BG-DT groups. Access site pain (p=0.014), back pain (p=0.023), and total pain (p=0.015) scores were significantly lower for the UG-ST than BG-DT group as assessed by the Visual Analog Scale. Over 20.2±8.7 months of follow up, there was no difference in AF recurrence free-survival rates between the two groups (Log rank, p=0.984).

CONCLUSION

UG-ST AF ablation is feasible and safe, and was found to significantly reduce post-procedural hemostasis-related discomfort, compared to the conventional DT approach, in patients with paroxysmal AF.

Inguinal vascular complications after ablation of atrial fibrillation: an economic impact assessment

Aims

Ablation of atrial fibrillation (AF) is recommended in the guidelines as a Class Ia/IIa indication. However, associated complications should not be dismissed; specifically, inguinal vascular complications (IVC). Although IVCs are generally considered trivial, they represent an economic burden for the procedure-performing hospital and the patient. Therefore, the ability to monitor and ultimately minimize potential complications is of considerable interest.

Methods and results

An economic model was developed to calculate the economic impact for certain IVC-types from a large German single-centre perspective in 2015 and 2016. Twenty-nine of 1040 (2.79%) and 48 of 1152 (4.17%) AF-ablation patients had documented IVC in 2015 and 2016 (P = 0.08), respectively. Inguinal vascular complications that required invasive treatment (thrombin, intervention, surgery) occurred in 0.58% of the 2015 and in 0.87% of the 2016 AF-ablation cases. The expected excess costs (incorporating direct costs, benefit lost adjusted for reimbursement) per patient treated with AF-ablation were 139.54€ and 153.31€ in 2015 and 2016, respectively. This was mostly driven by opportunity costs, which could reach 15 544.71€ for certain IVC. Sensitivity analysis revealed the probability of occurrence, length of stay of certain IVC types, and the revenue per day influenced the expected costs per AF-ablation patient.

Conclusion

Even relatively benign complications such as IVC can result in considerable cost increases. Therefore, measures to reduce them should be established and implemented.

When is it appropriate to stop non-vitamin K antagonist oral anticoagulants before catheter ablation of atrial fibrillation? A multicentre prospective randomized study

Aims

Although a recent expert consensus statement has recommended periprocedural uninterrupted (UI) non-vitamin K antagonist oral anticoagulants (NOACs) during catheter ablation of atrial fibrillation (AF) as a Class I indication, there have been no clear randomized trials. We investigated the safety and efficacy of UI, procedure day single-dose skipped (SDS), and 24-hour skipped (24S) NOACs in patients undergoing AF ablation.

Methods and results

In this prospective, open-label, randomized multicentre trial, 326 patients (75% male, 58 ± 11 years old) scheduled for AF catheter ablation were randomly assigned in a 1:1:1 ratio to UI, SDS, and 24S at three tertiary hospitals. Bridging with low molecular weight heparin was carried out in the patients with persistent AF who were assigned to the 24S group. Dabigatran, rivaroxaban, and apixaban were assigned in order after randomization. The primary endpoint was the incidence of bleeding events within 1 month after ablation. The secondary endpoints included thrombo-embolic and other procedure-related complications. The intra-procedural heparin requirement was higher in the 24S group than others (P < 0.001), and the mean activated clotting time was comparable among the groups (P = 0.139). The incidence of major bleeding up to 1 month after ablation and a post-procedural reduction in the haemoglobin levels did not significantly differ among the treatment groups and different NOACs (P > 0.05). There were no fatal events or thrombo-embolic complications in all the three groups.

Conclusion

In patients undergoing AF ablation, UI NOACs and SDS or double dose skipped NOACs had a comparable efficacy and safety, regardless of the type of NOAC.

Catheter ablation for atrial fibrillation on uninterrupted direct oral anticoagulants: A safe approach

BACKGROUND

Current consensus guidelines suggest direct oral anticoagulants (DOACs) are interrupted periprocedurally for catheter ablation (CA) of atrial fibrillation (AF). However, this may predispose patients to thromboembolic complications. This study investigates the safety of CA for AF on uninterrupted DOACs compared to uninterrupted warfarin.

METHODS

This was a single-center, retrospective study of consecutive patients undergoing CA for AF. All patients were heparinized prior to transseptal puncture with a target-activated clotting time (ACT) of 300-350 seconds. Patients who had procedures performed on continuous DOAC were compared to those on continuous warfarin. Clinical, procedural data, and complications occurring up to 3 months were analyzed from a prospective registry with additional review of electronic health records.

RESULTS

A total of 1,884 procedures were performed over 28 months: 761 (609 patients) on uninterrupted warfarin and 1,123 (900 patients) on uninterrupted DOAC (rivaroxaban 64%, apixaban 32%, and dabigatran 4%). There was no difference in the composite endpoint of death, thromboembolism, or major bleeding complication (2.2% vs 1.4%, P = 0.20). There was no difference in the complications comprising this, including tamponade, hematoma, pseudoaneurysm, and transfusion (P-values 0.28, 0.13, 0.45, and 0.36). There were no strokes, transient ischemic attacks, or other thromboembolic complications. There was no difference between groups in the proportion of tamponades requiring reversal of oral anticoagulation, the volume of blood lost, the proportion transfused, or the proportion drained percutaneously (P-values 0.50, 0.51, 0.36, and 0.38).

CONCLUSION

Catheter ablation for AF can be performed safely and effectively in patients anticoagulated with DOACs and heparinized with a therapeutic ACT. There is no increased risk of periprocedural bleeding when compared to uninterrupted warfarin.

Meta-analysis of safety and efficacy of oral anticoagulants in patients requiring catheter ablation for atrial fibrillation

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.