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Feasibility and Safety of Uninterrupted Rivaroxaban for Periprocedural Anticoagulation in Patients Undergoing Radiofrequency Ablation for Atrial Fibrillation: Results From a Multicenter Prospective Registry
Study Questions:
How does uninterrupted rivaroxaban compare to uninterrupted warfarin in patients undergoing catheter ablation of atrial fibrillation (AF)?
Methods:
In this multicenter, observational study, outcomes of 642 patients undergoing catheter ablation of AF without interruption of oral anticoagulation were compared. Rivaroxaban was continued in 321 patients and warfarin in the other 321 patients who were matched by gender, age, and AF type. All patients in the rivaroxaban group underwent a preprocedure transesophageal echocardiogram (TEE). In the warfarin group, a TEE was performed only in the seven patients (2%) with a subtherapeutic international normalized ratio (INR).
Results:
Patients were well matched, except for patients in the warfarin group had a higher HAS-BLED score (1.7 ± 1.0 vs. 1.5 ± 0.9; p = 0.03). There were no differences in major (5 [1.6%] vs. 7 [1.9%]; p = 0.77) or minor bleeding complications (16 [5.0%] vs. 19 [5.9%]; p = 0.60), or embolic complications (1 [0.3%] vs. 1 [0.3%]; p = 1.0) between the rivaroxaban and warfarin groups, respectively. Three patients in the rivaroxaban group, and four patients in the warfarin group underwent emergent pericardiocentesis, and none required cardiac surgery.
Conclusions:
In this nonrandomized comparison, bleeding and thromboembolic risks associated with uninterrupted rivaroxaban were similar to those with uninterrupted warfarin in patients undergoing left atrial ablation for AF.
Perspective:
In a prior study by the same authors, patients undergoing AF ablation with ‘near’-uninterrupted dabigatran, another novel oral anticoagulant (NOAC), experienced a higher risk of bleeding and thromboembolism as compared to warfarin. As a result, many centers recommend discontinuing NOACs prior to the procedure, and then restarting them after hemostasis. The results of the current study imply that the higher bleeding risk with dabigatran may not apply to other NOACs. Further, it is reassuring that the patients (albeit only three) in the rivaroxaban group who experienced cardiac perforation did not require emergent surgery. However, those in the rivaroxaban arm were probably somewhat lower-risk patients (lower HAS-BLED score, and all underwent TEE to rule out thrombus, as compared to only 7% of patients in the warfarin group). It is also unknown how patients taking rivaroxaban might fare if they required emergent surgery without an antidote.
Keywords: Thromboembolism, beta-Alanine, Morpholines, Benzimidazoles, Thiophenes, Warfarin, Atrial Fibrillation, Hemostasis, Cardiac Surgical Procedures, Catheter Ablation, Pericardiocentesis
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