Perspective:

This paper reviews periprocedural management strategies for patients undergoing atrial fibrillation (AF) ablation procedures while being treated with anticoagulants. The following are six key points to remember from the review:

1. Stroke occurs for various reasons before, during, and after an AF ablation procedure.

1. Before the ablation procedure, catheter manipulation may dislodge a previously formed thrombus in the left atrium. For this reason, guidelines recommend at least 4 weeks of therapeutic anticoagulation prior to the procedure.
   
   
2. During the ablation procedure, the passage of catheters into the left atrium and the insult of ablation on the left atrial tissue can trigger various aspects of the clotting cascade. For this reason, heparin is commonly given during the ablation procedure.
   
   
3. After the ablation procedure, stunning of the left atrium results in decreased contractility and an increased risk of thrombus formation. For this reason, guidelines recommend at least 2-3 months of anticoagulation post-procedure.
   

2. Periprocedural anticoagulation strategies must balance the prothrombotic risk with the bleeding risks at the access site and from cardiac perforation, a rare but serious complication from AF ablation procedures.

3. Two strategies are commonly used for periprocedural anticoagulation with warfarin.

1. The interrupted warfarin strategy involves holding warfarin 5 days preprocedure and initiating a heparin bridging strategy, usually 3 days preprocedure. During the procedure, heparin is usually given around the time of the trans-septal puncture. Warfarin is restarted post-procedure, with a heparin bridging strategy initiated several hours after sheath removal.
   
   
2. The uninterrupted strategy involves continuing therapeutic warfarin before, during, and after an AF ablation procedure with the use of intravenous heparin during the procedure. This strategy has been shown to have lower rates of bleeding complications than the interrupted warfarin strategy with heparin bridging.
   

4. Similar strategies have been studies with the newer nonvitamin K oral antagonists (NOACs).

1. For patients taking dabigatran, a minimally interrupted strategy can be employed. This strategy usually involves holding dabigatran 12-24 hours preprocedure and restarting dabigatran within 4-8 hours post-procedure. While there are less robust data than with the warfarin strategies, preliminary data from high-volume centers suggest this is a safe strategy.
   
   
2. For patients taking rivaroxaban, uninterrupted rivaroxaban has demonstrated similar safety and efficacy outcomes as uninterrupted warfarin in a few small studies.
   

5. Uninterrupted warfarin seems to have better outcomes than a strategy of interrupted warfarin with heparin bridging for AF ablation procedures. Use of a minimally interrupted or uninterrupted strategy with NOACs may have similar outcomes to the uninterrupted warfarin strategy, but further testing is needed.

6. While reversal agents for the NOACs are not available currently, there are a few antidotes in development and testing. In the future, these may prove to be helpful for patients who experience rare, but serious bleeding complications from AF ablation procedures.