Ablation of Atrial Fibrillation Without Left Atrial Appendage Imaging in Patients Treated With Direct Oral Anticoagulants

Circ Arrhythm Electrophysiol. 2020 Sep;13(9):e008301. doi: 10.1161/CIRCEP.119.008301. Epub 2020 Jul 24.

Abstract

Background: Many centers continue to routinely perform transesophageal echocardiograms before atrial fibrillation (AF) ablation procedures in patients treated with direct oral anticoagulants (DOACs). One study suggested that the procedures could be done without transesophageal echocardiogram but used intracardiac echocardiography imaging of the appendage from the right ventricular outflow. This study aimed to assess the safety of ablation for AF without transesophageal echocardiogram screening or intracardiac echocardiography imaging of the appendage in DOAC compliant patients.

Methods: All patients undergoing AF ablation at the Cleveland Clinic (2011-2018) were enrolled in a prospectively maintained data registry. All consecutive patients presenting with AF or atrial flutter on DOAC were included. Periprocedural thromboembolic complications were assessed.

Results: A total of 900 patients were included. Their median CHA2DS2-VASc score was 2 (interquartile range 1-3). All were on DOACs (333 rivaroxaban, 285 dabigatran, 281 apixaban, and 1 edoxaban). Thromboembolic complications occurred in 4 patients (0.3%): 2 ischemic strokes, 1 transient ischemic attack without residual deficit, and 1 splenic infarct; all with no further complications. Bleeding complications occurred in 5 patients (0.4%): 2 pericardial effusions (1 intraoperative, 1 after 30 days, both drained), 3 groin hematomas (1 of them due to needing heparin for venous thrombosis, none required interventions). No patients required emergent surgeries.

Conclusions: In DOAC compliant patients who present for ablation in AF/atrial flutter, the procedures could be performed without transesophageal echocardiogram screening or intracardiac echocardiography imaging of the appendage; with low risk of complications.

Keywords: atrial fibrillation; atrial flutter; echocardiography; stroke.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Atrial Appendage* / diagnostic imaging
  • Atrial Fibrillation / diagnostic imaging
  • Atrial Fibrillation / physiopathology
  • Atrial Fibrillation / therapy*
  • Atrial Flutter / diagnostic imaging
  • Atrial Flutter / physiopathology
  • Atrial Flutter / therapy*
  • Catheter Ablation* / adverse effects
  • Databases, Factual
  • Echocardiography, Transesophageal
  • Factor Xa Inhibitors / adverse effects
  • Factor Xa Inhibitors / therapeutic use*
  • Feasibility Studies
  • Female
  • Hemorrhage / chemically induced
  • Humans
  • Male
  • Middle Aged
  • Ohio
  • Prospective Studies
  • Pulmonary Veins / physiopathology
  • Pulmonary Veins / surgery*
  • Registries
  • Risk Assessment
  • Risk Factors
  • Stroke / prevention & control*
  • Thromboembolism / prevention & control*
  • Treatment Outcome
  • Unnecessary Procedures

Substances

  • Factor Xa Inhibitors