Radiofrequency ablation of atrial fibrillation under therapeutic international normalized ratio: a safe and efficacious periprocedural anticoagulation strategy

Heart Rhythm. 2009 Oct;6(10):1425-9. doi: 10.1016/j.hrthm.2009.07.007. Epub 2009 Jul 10.


Background: The best periprocedural anticoagulation strategy at the time of pulmonary vein isolation (PVI) is not known. Most centers stop administering warfarin (Coumadin) and use bridging with heparin or enoxaparin.

Objective: The purpose of this study was to evaluate the efficacy and safety of PVI under therapeutic international normalized ratio (INR).

Methods: Between January 2005 and December 2008, PVI was performed in 3,052 patients with therapeutic INR (> or =1.8) at the time of ablation. All patients were evaluated for ischemic strokes and bleeding complications.

Results: Mean INR was 2.53 +/- 0.62. Only 3 (0.098%) patients had ischemic strokes. One patient had a hemorrhagic stroke on the third day postablation but recovered completely by 1-week follow-up. Bleeding complications occurred in 34 (1.11%) patients; most were minor (0.79%). Major hemorrhagic complications occurred in 10 (0.33%) patients (tamponade in 5, hematomas requiring intervention in 2, transfusion necessary in 3).

Conclusion: In a large patient population, continuation of Coumadin at a therapeutic INR at the time of PVI without use of heparin or enoxaparin for bridging is a safe and efficacious periprocedural anticoagulation strategy. It is an acceptable and potentially better alternative to strategies that use bridging with heparin or enoxaparin.

MeSH terms

  • Anticoagulants / administration & dosage*
  • Anticoagulants / adverse effects
  • Atrial Fibrillation / surgery*
  • Catheter Ablation* / methods
  • Female
  • Follow-Up Studies
  • Hemorrhage / chemically induced
  • Humans
  • Male
  • Middle Aged
  • Postoperative Complications
  • Pulmonary Veins / surgery
  • Stroke / chemically induced
  • Warfarin / administration & dosage*
  • Warfarin / adverse effects


  • Anticoagulants
  • Warfarin