How to Use Novel Oral Anticoagulants during the Periprocedural Period of Atrial Fibrillation Ablation

Heparin bridging used to be a mainstream periprocedural anticoagulation strategy with warfarin at the dawn of catheter ablation of atrial fibrillation (AF). However, that was replaced by an uninterrupted warfarin strategy, because it was found to be more convenient and even safer This new strategy then reduced any cause for concern with regard to periprocedural hemorrhagic and thromboembolic complications. However, the times have changed. Novel oral anticoagulants (NOACs) without the need for laboratory monitoring have currently become available for patients with AF. Large scaled-trials have shown the non-inferiority or even a superiority of the NOACs over warfarin with regard to the occurrence of hemorrhagic or thromboembolic complications In response to the safety and convenience of the NOACs, they now are on track to take the place of warfarin as an anticoagulant therapy fornon-valvular AF. Thus, we cannot afford not to use NOACs during the periprocedural period of AF ablation. Studies then compared the hemorrhagic and a thromboembolic events occurring during the peri-procedural period of AF ablation between patients prescribed with an NOAC and those with warfarin. As it stands, there are 12 trials Of those, 10 trials [6-15] have compared dabigatran and warfarin. The vast majority of the studies Out of four Steinberg et al. [20] however reported in their meta analysis that neurological events; ischemic strokes or transient ischemic attacks, were more frequently observed during the periprocedural period of AF ablation in the dabigatran arm as compared to the uninterrupted warfarin arm (10/1501 [0.7%] versus 4/2356 [0.2%]). This non-negligible result could be explained purely by some pharmacological difference between warfarin and dabigatran, yet importantly it may have come from a lack of familiarity with the use of NOACs during the periablation period.