April 26, 2005Journal of Cardiovascular Electrophysiology180 citations
View Full PaperEmbolic Events and Char Formation During Pulmonary Vein Isolation in Patients with Atrial Fibrillation: Impact of Different Anticoagulation Regimens and Importance of Intracardiac Echo Imaging
Structured PICO
Do more aggressive anticoagulation regimens (higher ACT targets or addition of eptifibatide) reduce the incidence of char formation and embolic events during pulmonary vein isolation in patients with atrial fibrillation?
P
Population
785 patients (mean age: 54 years, 83.5% male) undergoing catheter-based pulmonary vein isolation (PVI) for treatment of drug refractory, symptomatic atrial fibrillation (AF).
I
Intervention
Group 2: Heparin targeting ACT 300-350 seconds plus IV eptifibatide (135 microg/kg bolus + 0.5 microg/kg/min); Group 3: Heparin targeting ACT 350-400 seconds.
C
Comparator
Group 1: Heparin targeting ACT 250-300 seconds.
O
Outcome
Incidence of char formation and embolic events.safety
More aggressive anticoagulation with heparin (ACT 350-400 seconds) significantly reduces periprocedural embolic events during pulmonary vein isolation for atrial fibrillation compared to lower ACT targets.
Abstract
UNLABELLED: Thromboembolic events are important complications of pulmonary vein isolation (PVI) procedures, occurring in up to 2.8% of patients. In this study, we report the incidence of char formation and embolic events with different anticoagulation protocols prospectively changed to reduce such complication. METHODS: A total of 785 patients (mean age: 54 years, 83.5% male) underwent catheter-based PVI for treatment of drug refractory, symptomatic atrial fibrillation (AF). PVI was performed utilizing different strategies including radiofrequency (RF) using temperature control energy delivery and RF using intracardiac echocardiography (ICE)-guided power titration. Patients were divided based on the anticoagulation protocol into three groups: in group 1 (194 patients), activation coagulation time (ACT) was maintained between 250 and 300 seconds; in group 2 (180 patients), ACT was maintained between 300 and 350 seconds plus the IV infusion of eptifibatide (135 microg/kg bolus + 0.5 microg/kg/min); and in group 3 (411 patients), ACT was maintained between 350 and 400 seconds. RESULTS: Char formation was detected in 69 patients of group 1, 5 of group 2, and 8 of group 3. An embolic event was observed in 7 patients of group 1, 3 of group 2, and 2 of group 3 (P = 0.01; group 1 vs group 3). Higher degree of anticoagulation with heparin was associated with a reduced incidence of embolic events even after removing the patients undergoing ICE-guided ablation (P = 0.04). CONCLUSION: More aggressive anticoagulation with heparin reduced periprocedural embolic events. The use of platelet inhibition does not have incremental beneficial effect. None of the anticoagulation protocol abolished char formation.