Peri-ablation dabigatran in atrial fibrillation: not only about
thromboembolism.
We have read with interest the letter by Ward (1) about our recent
publication (2). The author raised an important point: why should
dabigatran be interrupted during a procedure known to be associated with
risk of thromboembolic events? Ward also noted that our meta-analysis did
not include any study with uninterrupted dabigatran. While it is true that
left atrial ablation procedures are associated with risk of
thromboembolism, they also carry risk of potentially life threatening
bleeding.
Given the low thromboembolism and bleeding rates with uninterrupted
warfarin, it would appear reasonable to consider the use of uninterrupted
dabigatran. Factors that have deterred its use include lack of an antidote
and the overall lesser clinical experience with the medication in
comparison to warfarin. An increased requirement for intra-procedural
heparin with peri-ablation dabigatran (3), and prior report of more
bleeding with peri-ablation dabigatran (4) use may have also limited use
of this approach.
Importantly, most of the available studies have examined interrupted
dabigatran versus warfarin (often uninterrupted), and the results of
several meta-analyses (5,6,7) have shown a comparable efficacy and safety
profile for the two anticoagulants. We limited our analysis to studies
that compared interrupted dabigatran with warfarin therapy to minimize in
between studies heterogeneity that would impact interpretation and
applicability the results. If more data become available on uninterrupted
dabigatran use, it could become a more widely accepted approach if safety
is proven.
References:
1. Ward D. Have I missed something here? . Heart.2013. (In press)
2. Bin Abdulhak AA, Khan AR, Tleyjeh IM, et al. Dabigatran in the
setting of catheter ablation of atrial fibrillation: the road ahead. Heart
Published Online First: [10/14/2013] doi: 10.1136/heartjnl-2013-304989
3. Konduru SV, Cheema AA, Jones P,et al. Differences in intra-
procedural ACTs with standardized heparin dosing during catheter ablation
for atrial fibrillation in patients treated with dabigatran vs. patients
on uninterrupted warfarin. J Interv Card Electrophysiol 2012; 35: 277 -
84.
4. Lakkireddy D,Reddy YM,Di Biase L,et al.Feasibility and safety of
dabigatran versus warfarin for periprocedural anticoagulation in patients
undergoing radiofrequency ablation for atrial fibrillation: results from a
multicenter prospective registry. J Am Coll Cardiol 2012;59:1168-74.
5. Bin Abdulhak AA, Khan AR, Tleyjeh IM, 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) 15 (10): 1412-1420
6. Providencia R, Albenque J-P, Combes S, et al. Safety and efficacy
of dabigatran versus warfarin in patients undergoing catheter ablation of
atrial fibrillation: a systematic review and meta-analysis. Heart
Published Online First: 22 July 2013 doi: 10.1136/heartjnl-2013- 304386.
7. Hohnloser S, Camm A. Safety and efficacy of dabigatran etexilate
during catheter ablation of atrial fibrillation: a meta-analysis of the
literature. Europace 2013;15(10):1407-11.
Conflict of Interest:
None declared
Peri-ablation dabigatran in atrial fibrillation: not only about thromboembolism.
We have read with interest the letter by Ward (1) about our recent publication (2). The author raised an important point: why should dabigatran be interrupted during a procedure known to be associated with risk of thromboembolic events? Ward also noted that our meta-analysis did not include any study with uninterrupted dabigatran. While it is true that left atrial ablation procedures are associated with risk of thromboembolism, they also carry risk of potentially life threatening bleeding.
Given the low thromboembolism and bleeding rates with uninterrupted warfarin, it would appear reasonable to consider the use of uninterrupted dabigatran. Factors that have deterred its use include lack of an antidote and the overall lesser clinical experience with the medication in comparison to warfarin. An increased requirement for intra-procedural heparin with peri-ablation dabigatran (3), and prior report of more bleeding with peri-ablation dabigatran (4) use may have also limited use of this approach. Importantly, most of the available studies have examined interrupted dabigatran versus warfarin (often uninterrupted), and the results of several meta-analyses (5,6,7) have shown a comparable efficacy and safety profile for the two anticoagulants. We limited our analysis to studies that compared interrupted dabigatran with warfarin therapy to minimize in between studies heterogeneity that would impact interpretation and applicability the results. If more data become available on uninterrupted dabigatran use, it could become a more widely accepted approach if safety is proven.
References:
1. Ward D. Have I missed something here? . Heart.2013. (In press)
2. Bin Abdulhak AA, Khan AR, Tleyjeh IM, et al. Dabigatran in the setting of catheter ablation of atrial fibrillation: the road ahead. Heart Published Online First: [10/14/2013] doi: 10.1136/heartjnl-2013-304989
3. Konduru SV, Cheema AA, Jones P,et al. Differences in intra- procedural ACTs with standardized heparin dosing during catheter ablation for atrial fibrillation in patients treated with dabigatran vs. patients on uninterrupted warfarin. J Interv Card Electrophysiol 2012; 35: 277 - 84.
4. Lakkireddy D,Reddy YM,Di Biase L,et al.Feasibility and safety of dabigatran versus warfarin for periprocedural anticoagulation in patients undergoing radiofrequency ablation for atrial fibrillation: results from a multicenter prospective registry. J Am Coll Cardiol 2012;59:1168-74.
5. Bin Abdulhak AA, Khan AR, Tleyjeh IM, 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) 15 (10): 1412-1420
6. Providencia R, Albenque J-P, Combes S, et al. Safety and efficacy of dabigatran versus warfarin in patients undergoing catheter ablation of atrial fibrillation: a systematic review and meta-analysis. Heart Published Online First: 22 July 2013 doi: 10.1136/heartjnl-2013- 304386.
7. Hohnloser S, Camm A. Safety and efficacy of dabigatran etexilate during catheter ablation of atrial fibrillation: a meta-analysis of the literature. Europace 2013;15(10):1407-11.
Conflict of Interest:
None declared