OAC after apparently successfull AF ablation: when, why, and how?

Transcription

1 Gulf EP Live Dubai January / 2015 OAC after apparently successfull AF ablation: when, why, and how? Antonio Raviele, MD, FESC, FHRS Past Director Cardiovascular Department, dell Angelo Hospital, Venice-Mestre, Italy

2 Europace 2012; 14:

3 J Cardiovasc Electrophysiol 2012; 23:

4 Recommendations for Anticoagulation Therapy in Patients Undergoing AF Ablation Systemic anticoagulation with warfarin or a direct thrombin or Factor Xa inhibitor is recommended for at least two months following an AF ablation procedure. Discontinuation of systemic anticoagulation therapy post ablation is not recommended in patients who are at high risk of stroke as estimated by currently recommended schemes (CHADS2 or CHA2DS2VASc). Calkins H et al. Europace 2012; 14: Oral anticoagulation should be started after ablation and continued for at least 3 months in all patients. Oral anticoagulation should be continued indefinitely in most patients who are at moderate or high risk of stroke (based on a risk stratification system such as CHADS 2 or CHA 2 DS 2 -VASc). Raviele A et al. J Cardiovasc Electrophysiol 2012; 23:

5 Discontinuation of OAT after ablation These recommendations come from trials essentially performed in patients treated with antiarrhythmic drugs Only limited data are available in the literature regarding the risk of thromboembolism after successful ablation of AF.

6 Anticoagulation in AF How safe is and when to withdraw anticoagulation in post-ablation patients?

7 Main consideration in favour of OAT Atrial fibrillation is not rarely asymptomatic after AF ablation

8 10% Raviele A et al. J Cardiovasc Electrophysiol 2012; 23:

9 Asymptomatic AF / Detection Methods Standard-12 lead ECG 24-h / 7-d Holter monitoring In-hospital telemetry Mobile continuous outpatient telemetry Event recorder / Intermittent TTEM PM - ICD Device memory External & Implantable loop recorder

10 Prevalence of Asymptomatic AF (%) Discovered incidentally / ECG During AAD Therapy / TTEM PM ICD recipients / Device memory Post-AF Ablation / TTEM, 7-d Holter, 0-20

11 Asymptomatic AF The majority of these episodes are of brief duration and the clinical significance and therapeutic implications of short-lasting asymptomatic AF are still uncertain

12 Another consideration in favour of OAT RF catheter ablation of AF is a procedure that causes an extensive damage of atrial myocardium (up to 20%-30%). The resulting areas of scarring might depress left atrial contractility and predispose to atrial thrombi formation, independent of atrial arrhythmia recurrences

13 AF Ablation & LA Function does AF ablation really impair left atrial function?

14 Effect of RF ablation on LA mechanical function Pts # RF technique LA Function LA size Imaging technique Pappone 01 Lemola 04 Lemola 05 Reant 05 Beukema 05 Tops 05 Verma 06 Takahashi 07 Sacher 08 Marsan 08 Schneider 08 Tops CPVA LACA LACA PVI LACA PVI+LL PVAI Stepwise Stepwise PVI+LL PVI PVI TTE/TEE CT CT TTE TTE TTE TTE/CT TTE TTE RT3DE TTE TTE

15 Eur Heart J 2014; Epub before print January 31, 2014

16 72 Centres in 10 European Countries Eur Heart J 2014; Epub before print January 31, 2014

17 Rate of use of pharmacological treatment at discharge and at the 12-month follow-up. 36% of pts with CHA2DS2-Vasc = 1 24% of pts with CHA2DS2-Vasc > 1 Arbelo E et al. Eur Heart J 2014;eurheartj.ehu001

18 OAT discontinuation after AF ablation The correctness of this behaviour seems to be confirmed by the results of several retrospective studies published in the last years

19 Pts Total Pts in SR Off OAC TE RF 1 FU mths TE (%) Off OAC On OAC Major Bl Oral Nademanee NR Themistoclakis 2010 Off OAC NR Saad Hunter NR Guiot Winkle NR Lin NR NR NR NR NR NR Gaita Riley On OAC Total (81) 6579 (64) 2484 (24) (0.7) 35 (0.5) 35 (1.0) 62 (0.6) 4 (0.06) 57 (1.8)

20 J Am Coll Cardiol 2010; 55:

21 Patient population 3355 Study group: 2692 (80%) Control group: 663 (20%) Themistoclakis S et al. J Am Coll Cardiol 2010; 55:

22 Incidence of Embolic and Hemorrhagic Events Mean follow up: and months Study Group Control Group p Patients, n (%) Tromboembolic events, n (%) 2 (0.07) 3 (0.45) 0.06 Hemorrhagic events, n (%) 1 (0.04) 13 (2.0) <0.001 Themistoclakis S et al. J Am Coll Cardiol 2010; 55:

23 Themistoclakis S et al. J Am Coll Cardiol 2010; 55:

24 Considerations These results suggest that the risk-benefit ratio favors suspension of OAT after successful AF ablation even in pts at moderate-high risk of thromboembolism Themistoclakis S et al. J Am Coll Cardiol 2010; 55:

25 Oral anticoagulation therapy after radiofrequency ablation of atrial fibrillation and the risk of thromboembolism and serious bleeding: long- term follow-up in nationwide cohort of Denmark Deniz Karasoy1*, Gunnar Hilmar Gislason1,2, Jim Hansen1, Arne Johannessen1, Lars Køber3, Morten Hvidtfeldt1, Cengiz O zcan1, Christian Torp-Pedersen1,4, and Morten Lock Hansen1 Eur Heart J 2014;eurheartj.ehu421

26 The cumulative incidences of thromboembolism and serious bleeding according to oral anticoagulation therapy (4050 pts, mean follow-up 3,4 years) Annual incidence of thromboembolism Off-OAC = 0.64% On-OAC = 0.56% Annual incidence of serious bleeding Off-OAC = 0.44% On-OAC = 0.99% Karasoy D et al. Eur Heart J 2014;eurheartj.ehu421

27 Conclusions Thromboembolic risk beyond 3 months after RFA was relatively low compared with a matched non-ablated AF cohort. With cautious interpretation due to low number of events, serious bleeding risk associated with OAC seems to outweigh the benefits of thromboembolic risk reduction

28 Gulf EP Live Dubai January / 2015 OAC after apparently successfull AF ablation: when, why, and how? Antonio Raviele, MD, FESC, FHRS Past Director Cardiovascular Department, dell Angelo Hospital, Venice-Mestre, Italy

29 Suggestions for OAT after ablation (1) The decision to discontinue OAT after apparently successful AF ablation should be still based, in the single patient, on the careful evaluation of the risk/benefit balance between prevention of ischemic stroke and avoidance of hemorrhagic complications

30 Suggestions for OAT after ablation (2) However, according to the results of the above mentioned retrospective studies performed till now, it seems that OAT may be safely interrupted in the majority of post-ablation patients, including those at high trombo-embolic risk

31 Suggestions for OAT after ablation (3) However, this conclusion needs to be confirmed by prospective randomized studies with a sufficient number of patients (at least 3000 patients)

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34 Individual predictors associated with thromboembolism and serious bleeding after first-time radiofrequency ablation. Karasoy D et al. Eur Heart J 2014;eurheartj.ehu421

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