Key result
Uninterrupted warfarin is linked to ~21-point fewer bleeding and groin complications vs. LMWH bridging.
Why the study?
Many patients undergoing catheter ablation of atrial flutter require periprocedural anticoagulation, but the optimal anticoagulation strategy is unclear.
Case-Control (n=101)
Answers are grounded in this paper and cite their sources.
Uninterrupted warfarin was associated with fewer complications and lower costs in AFL ablation; leaves open need for randomized trials before practice change.
INTRODUCTION: Many patients undergoing catheter ablation of atrial flutter (AFL) require periprocedural anticoagulation. We compared a strategy of conversion to low molecular weight heparin (LMWH) periprocedure to uninterrupted warfarinization in a nonrandomized, case-controlled study. METHODS: One hundred and one consecutive patients requiring periprocedural anticoagulation for catheter ablation of typical AFL were studied. The first 51 patients underwent conversion to LMWH (enoxaparin 1 mg/kg bd) with a warfarin pause (LMWH group), the subsequent 50 continued with uninterrupted oral anticoagulation (Warfarin group). Primary endpoint was a composite of major and minor bleeding complications and groin symptoms. RESULTS: Fewer patients in the Warfarin group reached the primary endpoint (36.0% vs 56.8%, P = 0.013). Four patients in the LMWH group but no patient in the Warfarin group required hospital admission for bleeding-related complications. Cost analysis showed mean cost per patient of anticoagulation with LMWH to be pounds sterling 100.9 (95% CI 94.46-107.30) compared to pounds sterling 10.23 (4.49-15.97) in the Warfarin group (P < 0.0001). Transesophageal echocardiography (TEE) was performed prior to ablation in 11 patients in the Warfarin group and in 3 patients in the LMWH (P = 0.019). When TEE costs were included, costs were pounds sterling 125.00 ($188.25) (96.80-153.60) for the LMWH strategy and pounds sterling 108.5 ($163.40) (54.92-162.1) for the Warfarin group (P < 0.0001). CONCLUSIONS: Catheter ablation of typical AFL without interruption of warfarin appears safer and more cost-effective than periprocedural conversion to LMWH. It could be used as a routine anticoagulation strategy for the ablation of right-sided arrhythmias.
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Finlay et al. (2009) conducted a case-control in Typical atrial flutter requiring catheter ablation (n=101). Uninterrupted oral anticoagulation (Warfarin) vs. Conversion to low molecular weight heparin (LMWH) with a warfarin pause was evaluated on Composite of major and minor bleeding complications and groin symptoms (p=0.013). Uninterrupted warfarin during typical atrial flutter ablation resulted in fewer bleeding complications and groin symptoms compared to periprocedural LMWH conversion (36.0% vs 56.8%, P=0.013).
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