Stroke and Bleeding Risks of Endocardial Ablation for Ventricular Arrhythmias

Quick Takes

  • Following ablation for ventricular arrhythmia, an individualized approach to antithrombotic therapy with aspirin 325 mg daily for most patients and more potent anticoagulants for selected patients is associated with a very low risk of embolic events.
  • A precision medicine approach for guiding antithrombotic regimens in patients requiring ablation for ventricular arrhythmia can potentially select the regimen according to the patient’s profile.

Study Questions:

What is the incidence of the embolic and bleeding complications in relation to pre- and post- periprocedure antithrombotic regimens in patients undergoing ventricular arrhythmia radiofrequency ablation (RFA)?


The authors conducted a prospective assessment of complications in patients undergoing endocardial ventricular arrhythmia RFA.


A total of 663 endocardial RFA procedures were performed in 616 consecutive patients (72% cardiomyopathy, 45% sustained ventricular tachycardia). There were two strokes (0.3%; 95% confidence interval [CI], 0.0%-0.8%), one transient ischemic attack (TIA) (0.15%), and two pulmonary emboli (0.3%). Bleeding complications occurred in 6% of patients. Pre-procedure, 464 (70%) patients were taking antithrombotic agents, including 220 (33%) taking aspirin alone, and 163 (25%) taking warfarin or a direct acting oral anticoagulant (DOAC). Pre-procedure nonaspirin antiplatelet use (odds ratio [OR], 2.846; p = 0.011) and DOAC use (OR, 2.585; p = 0.032) were associated with risk of bleeding complications. Following ablation, 50% of patients were treated with aspirin 325 mg daily, and 30% received DOACs or warfarin. New DOAC or warfarin administration was initiated in only 7% of patients. Overall, 40% of patients continued the same pre-procedure antithrombotic regimen.


The authors conclude that stroke is a rare complication of RFA for ventricular arrhythmia using aspirin 325 mg daily as a minimal post-procedure regimen with more potent regimens for selected patients.


The majority of ablation-related complications are related to either bleeding or clotting problems, and the electrophysiologists walk a tightrope between strokes and pericardial effusions and other vascular injury. The present study does not address the intraprocedural anticoagulation issues, but rather looks at the value of oral anticoagulation post-ablation procedure in patients who have no other indication for oral anticoagulants. There has been very little guidance in this respect. Most physicians use antiplatelet agents for “less extensive” ablation and oral anticoagulant therapy after “extensive” ablation. A prior study suggested that aspirin 81 mg daily may be insufficient to prevent embolic events.

In the present study, patients who did not have pre-procedure indication for anticoagulation and who did not have high-risk features were prescribed full-dose aspirin for 4-6 weeks or were continued on the previous nonaspirin antiplatelet agent. All other patients were put on heparin starting 4-8 hours post-procedure and resumed anticoagulation or had uninterrupted anticoagulation. The authors report that despite only 6% of patients receiving a new regimen with a DOAC or warfarin after ablation, the risk of embolic events was low, with the incidence of stroke being 0.3%, TIA 0.15%, and pulmonary embolism 0.3%, suggesting that many patients can do without oral anticoagulants.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Radiofrequency Ablation, Stroke

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