Perspective:

Despite the growing practice of performing electrophysiologic procedures without the interruption of oral anticoagulation, the use of heparin or heparin-like agents is essential to prevent thrombus formation in the sheath, on the catheter tip, or in situ during ablation. Contraindications to heparin use are very infrequent, but in the few patients who cannot receive heparin due to history of heparin-induced thrombocytopenia, heparin or protamine allergy, resistance to heparin, or religious prohibition (swine product), direct thrombin inhibitors are the only other option if invasive strategy is to be pursued. While there is a great deal of literature on direct thrombin inhibitors in the catheterization laboratory, there have been very few reports in the electrophysiology laboratory. In the present study, the authors show that direct thrombin inhibitors appear to be safe and effective in the retrospective cohort of 53 patients undergoing left atrial or ventricular procedures. The relative efficacy of unfractionated heparin versus bivalirudin or argatroban in the setting of an electrophysiologic procedure is unknown, and such an assessment might require a prohibitively large sample.