Uninterrupted vs. interrupted non-vitamin K antagonist oral anticoagulant during atrial fibrillation catheter ablation: expert opinion or true evidence?

This commentary refers to ‘2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS)’, by G. Hindricks et al., doi:10.1093/eurheartj/ehaa612. The management of anticoagulation in patients undergoing catheter ablation of atrial fibrillation (AF) is critical to limit complications. Over the last decade, the standard protocol has moved from a strategy of stopping vitamin K antagonist (VKA) with heparin bridging to uninterrupted VKA. This change gained wide acceptance among electrophysiologists based on the evidence provided by the randomized comparison of both strategies showing a reduced risk of minor bleedings and, more importantly, of periprocedural stroke. Compared with VKA, the quicker offset and onset of anticoagulation of non-vitamin K antagonist oral anticoagulant (NOAC) allows different strategies in their use. The safety and efficacy of both minimally interrupted (i.e. holding 1 or 2 doses) and uninterrupted NOAC strategies have been demonstrated and both strategies were endorsed by the 2017 consensus document of the EHRA and HRS. Notwithstanding, the adoption of a truly uninterrupted NOAC strategy has been slow and a minority of centres were implementing this strategy in recent European surveys. In the recent 2020 ESC guidelines for the diagnosis and management of AF,1 the uninterrupted strategy now becomes the only endorsed strategy for VKA and NOAC in patients undergoing AF ablation. A Class I indication with level of evidence A is provided. While clear evidences support an uninterrupted strategy with VKA, evidences to support this strategy over a minimally interrupted strategy for NOAC are lacking. The randomized trials and the meta-analysis cited to support the level of evidence A, actually exclusively compared two drug classes (VKA and NOAC), but not the two strategies, which obviously represents the actual electrophysiologist’s dilemma. Most randomized trials have indeed been performed with the uninterrupted strategy but a growing body of evidence has evaluated whether one NOAC strategy should be preferred over the other. Two recent randomized trials compared periprocedural uninterrupted NOAC to minimal NOAC interruption. In both studies, no significant differences between randomized groups were found for thrombo-embolic events or major bleeding.2,3 Additionally, two meta-analyses of prospective or randomized studies compared the continuous vs. minimally interrupted NOAC strategy to uninterrupted VKA. Both studies showed that the two NOAC strategies were safe and non-inferior.4,5 In light of these observations, the assignment of a Class I recommendation for uninterrupted NOAC as a sole recommended strategy without evidence, or even signals, of adverse outcome with minimally interrupted strategies seems questionable. This change should take into account the real-world consequences of implementing uninterrupted strategies in low-volume centres with less expertise, which perform transseptal puncture without additional cardiac imaging, in centres without immediate access to surgical therapies or NOAC antidotes. Indeed, the randomized trials on periprocedural NOAC during AF ablation have been performed in experienced centres and share in common the fact of not being powered to assess the risk (and management) of the most feared complications, namely uncontrolled periprocedural bleeding and thromboembolism. It seems therefore reasonable to consider a minimally interrupted NOAC strategy still acceptable until larger studies are able to demonstrate that the uninterrupted strategy provides the best trade-off between thrombo-embolic events and major bleeding. Conflict of interest: none declared.