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Uninterrupted anticoagulation with vitamin K antagonists during ablation and device implantation

The European Society of Cardiology ( ESC ) has recommended uninterrupted anticoagulation with vitamin K antagonists during ablation and device implantation in a position paper presented at EHRA EUROPACE – CARDIOSTIM 2015.

Traditionally anticoagulation is interrupted during device implantation and restarted it afterwards, with Heparin bridging around the time of the operation.
The new recommendation is to continue to give the vitamin K antagonist and perform the operation without any bridging. That shows the lowest rate of perioperative bleeding.

Also new is the recommendation not to interrupt vitamin K antagonists during ablation and particularly during pulmonary vein isolation which is the most common type of ablation nowadays.

The recommendations are an update of EHRA’s 2008 consensus document. Dramatic changes in the field during the last five years demanded a revision. There has been a steep rise in device implantation and even greater increases in ablation procedures, mainly pulmonary vein isolation.
Since 2008 new drugs have been introduced, namely the non-vitamin K antagonist oral anticoagulants ( also called new oral anticoagulants or NOACs ) and the antiplatelets Prasugrel and Ticagrelor.

Three main topics are covered: antithrombotic management in patients undergoing ablation for various conditions such as atrial fibrillation; antithrombotic management for the implantation or exchange of cardiac implantable electronic devices ( CIEDs ) including pacemakers, implantable cardioverter defibrillators ( ICDs ) and cardiac resynchonisation therapy ( CRT ) systems; and peri-interventional bleeding complications on concurrent antiplatelet therapy.

Recommendations on NOACs are given for the first time.

The document recommends interruption of NOACs for device surgery, without Heparin bridging. This advice is consistent with the EHRA Practical Guide on the use of NOACs in patients with non-valvular atrial fibrillation.
The period of discontinuation should be based on individual product monographs, and the drug restarted 24 to 48 hours after surgery.

The document also recommends interrupting NOACs during ablation with pulmonary vein isolation, with the last dose given 24 hours before in patients with normal renal function.

The most controversial topic was the use of transoesophageal echocardiography ( TEE ) to screen for thrombi prior to ablation to prevent strokes.
Virtually all Europeans do TEE before ablation even if the stroke risk is low or the patient presents in sinus rhythm. The Americans have a higher threshold for performing TEE and this generated a lot of debate. ( Xagena )

Source: ESC ( European Society of Cardiology ), 2015