To The Editor:
We read with interest the study by Providencia et al. which
demonstrated that dabigatran had a similar efficacy and safety profile as
warfarin in the setting of catheter ablation (CA) of atrial fibrillation
(AF) (1). These findings concur with two other meta-analyses on the same
topic (including one from our group) which have been recently published
(2,3). All the published meta-analyses on this topic were limited by the
hierarchy of evidence, which was mostly derived from observational
studies. These observations warrant validation by a randomized controlled
trial. However, patients will probably undergo the procedure while on
dabigatran based on the current available evidence until a controlled
study is carried out. How to manage the drug peri-procedurally and
minimize the risks of bleeding and thromboembolism are importance points
to be considered. A reasonable approach based on the importance of
limiting interruption to peri-procedural anticoagulation and considering
the pharmacokinetics of dabigatran is to hold 1-2 doses of dabigatran and
resume the medication a shortly after achieving post-procedural hemostasis
at the vascular access site. Indeed, in our analysis limited to studies
that held 1-2 doses of dabigatran and resumed the drug on the same day as
the procedure, we not only found no significant difference in bleeding or
thromboembolic events between interrupted dabigatran and uninterrupted
warfarin, but importantly there was zero to mild in between studies
heteterogenity. Also, it is reasonable to consider transesophageal
echocardiography (TEE) before CA of AF in patients on dabigatran given the
relatively lesser experience with the drug and the fact that most reported
studies have used TEE before the ablation procedure.
References:
1.Providencia, R., Albenque, J-P., Combes, S.,et al. Heart Published
Online First: 2013 Jul 22 doi:10.1136/ heartjnl-2013-304386
2.Bin Abdulhak, A., Khan, AR. ,Tleyjeh,I.,et al.Safety and efficacy
of interrupted dabigatran for peri-procedural anticoagulation in catheter
ablation of atrial fibrillation: a systematic review and meta-
analysis.Europace. 2013 August 16 doi: 10.1093/europace/eut239
3.Hohnloser, S., Camm, A. Safety and efficacy of dabigatranetexilate
during catheter ablation of atrial fibrillation: a meta-analysis of the
literature.Europace. 2013 August 16 doi:10.1093/europace/eut241
Conflict of Interest:
None declared
To The Editor:
We read with interest the study by Providencia et al. which demonstrated that dabigatran had a similar efficacy and safety profile as warfarin in the setting of catheter ablation (CA) of atrial fibrillation (AF) (1). These findings concur with two other meta-analyses on the same topic (including one from our group) which have been recently published (2,3). All the published meta-analyses on this topic were limited by the hierarchy of evidence, which was mostly derived from observational studies. These observations warrant validation by a randomized controlled trial. However, patients will probably undergo the procedure while on dabigatran based on the current available evidence until a controlled study is carried out. How to manage the drug peri-procedurally and minimize the risks of bleeding and thromboembolism are importance points to be considered. A reasonable approach based on the importance of limiting interruption to peri-procedural anticoagulation and considering the pharmacokinetics of dabigatran is to hold 1-2 doses of dabigatran and resume the medication a shortly after achieving post-procedural hemostasis at the vascular access site. Indeed, in our analysis limited to studies that held 1-2 doses of dabigatran and resumed the drug on the same day as the procedure, we not only found no significant difference in bleeding or thromboembolic events between interrupted dabigatran and uninterrupted warfarin, but importantly there was zero to mild in between studies heteterogenity. Also, it is reasonable to consider transesophageal echocardiography (TEE) before CA of AF in patients on dabigatran given the relatively lesser experience with the drug and the fact that most reported studies have used TEE before the ablation procedure.
References:
1.Providencia, R., Albenque, J-P., Combes, S.,et al. Heart Published Online First: 2013 Jul 22 doi:10.1136/ heartjnl-2013-304386
2.Bin Abdulhak, A., Khan, AR. ,Tleyjeh,I.,et al.Safety and efficacy of interrupted dabigatran for peri-procedural anticoagulation in catheter ablation of atrial fibrillation: a systematic review and meta- analysis.Europace. 2013 August 16 doi: 10.1093/europace/eut239
3.Hohnloser, S., Camm, A. Safety and efficacy of dabigatranetexilate during catheter ablation of atrial fibrillation: a meta-analysis of the literature.Europace. 2013 August 16 doi:10.1093/europace/eut241
Conflict of Interest:
None declared