Ceasing anticoagulation after ablation associated tamponade does not increase stroke risk

Background Tamponade is the most common serious adverse event of atrial fibrillation (AF) ablation. It presents a conundrum as the risk of further bleeding with anticoagulation must be balanced against the risk of stroke, which is most significant in the early period after ablation. Purpose We sought to define the risks associated with continuing versus interrupting anticoagulation after AF ablation associated tamponade Methods We performed an international, multi-centre cohort study of individuals with tamponade following AF ablation. We included n=141 tamponade cases drawn from 19,727 AF ablations performed at five centres from the UK, USA, Australia, France and Spain. Baseline covariates included demographics, CHADS-VASc score, ablation details and lab results. We defined interrupted anticoagulation as any ³24-hour period without full dose anticoagulation. The primary outcome was stroke or systemic embolism at 90 days post-procedure. Secondary outcomes included drain volumes, cardiac surgery, hospital length of stay, haemoglobin drop, blood transfusion and early recurrence of AF (ERAF). Results Of 141 cases, 82% (n=116) had interrupted anticoagulation vs 18% (n=25) who continued anticoagulation. Baseline characteristics were similar between groups with mean ages of 71.4 ± 7.9 vs 67.4 ± 9.9 (p=0.06), 46% vs 52% males (p=0.7) and CHADS-VASc of 2.4 ± 1.4 vs 2.0 ± 1.0 (p=0.7) respectively. Overall mean LV ejection fraction was 44% ± 16% and 46.8% had paroxysmal AF. The median time of anticoagulation interruption was 1 day (IQR: 1.25) with a maximum of 20 days. There were no strokes or systemic embolism in any of the participants. There were two deaths within 90 days, both of which occurred in the interrupted anticoagulation group relating to complications of tamponade. Participants in the interrupted anticoagulation group had larger pericardial drain volumes (876.7mL ± 626.7mL vs 604.5mL ± 384.0mL, p=0.007). There was a trend toward higher blood transfusion rates in the interrupted anticoagulation group (OR 2.4, p=0.2) with drain volume being a significant predictor (p<0.001). Hospital stay was longer by 2.4 days (0.5 to 4.9, p=0.02) in patients with interrupted anticoagulation. There was no difference in ERAF at 90 days (50% vs 43%, p=0.6) Conclusion Interrupting anticoagulation after AF ablation complicated by tamponade does not increase stroke or systemic embolism. The main clinical events after ablation associated tamponade are bleeding-related and thus, interruption of anticoagulation is reasonable.