Skip TEE Before AF Ablation With No-Bridge Continuous NOACs: Early Experience

May 14, 2015

BOSTON, MA — If they have been on a new oral anticoagulant (NOAC) for at least a month, patients slated for ablation of atrial fibrillation (AF) can stay on the NOAC during the procedure, without heparin bridging, and not undergo transesophageal echocardiography (TEE) to screen for atrial thrombus, propose researchers based on their multicenter cohort study[1]. It suggests that skipping TEE, which adds time and cost to the procedure and is onerous for the patient, is feasible and safe when NOACs are on board continuously, they say.

Uninterrupted warfarin remains the conventional approach, but TEE is then often performed before ablation if the patient hasn't logged 4 weeks of INRs in the therapeutic range or isn't in sinus rhythm on procedure day, Dr Luigi Di Biase (Texas Cardiac Arrhythmia Institute at St David's Medical Center, Austin) told heartwire from Medscape. On the other hand, in such cases, "there are studies that have shown that you don't need to do TEE."

That's with warfarin, he emphasized. "With NOACs, we don't know," and so TEE is generally included when AF ablation is done on those agents. Support for doing away with the TEE step, Di Biase noted, comes from research suggesting that it isn't needed in patients who have been on rivaroxaban (Xarelto, Bayer Pharma/Janssen Pharmaceuticals) before AF cardioversion.

In the current study, which Di Biase presented here at the Heart Rhythm Society 2015 Scientific Sessions, patients had been on either rivaroxaban or apixaban (Eliquis, Bristol-Myers Squibb/Pfizer). By avoiding TEE in patients on the agents for at least 4 weeks, he said, "we save a lot of money, we save a lot of time."

Before ablation without TEE, his group scans the left atrial appendage (LAA) for signs of thrombus using intracardiac echocardiography, which is already in place to guide the transeptal puncture needed for the ablation procedure. That only takes a few extra seconds, Di Biase said.

Dr Charles D Swerdlow (Cedars Sinai Heart Center, Los Angeles), who isn't connected with the study, said to heartwire that he wouldn't yet run with its results as if they had appeared in a peer-reviewed journal. "But I'm very impressed."

Withholding NOACs and then bridging with heparin "is the worst thing you can do," he said, as it increases the risk of bleeding complications and makes the whole procedure more complicated. Still, at his center, "we have been stopping our NOACs for 24 hours and then restarting them right after the procedure. We're not really sure if that's the right thing to do. If [these researchers] are telling us we should do [NOACs] uninterrupted, it would just simplify the whole thing."

And by avoiding TEE, one would avoid even the risks that procedure can entail, Swerdlow observed. "If you do a thousand TEEs, someone's going to have a complication from that, too—an esophageal problem or an airway problem."

Di Biase and his colleagues prospectively observed 970 patients, including 15% with paroxysmal and 85% nonparoxysmal AF, who were on either rivaroxaban or apixaban for at least 4 weeks before undergoing ablation of their arrhythmia. Their mean CHA2DS2-VASc score was 3.01.

Intracardiac echocardiography showed an absence of LAA thrombus in all patients and only "smoke," a marker of blood stasis, in 42% of cases. MRI in a subset of 54 patients show no instances of silent cerebral ischemia, although there was one MRI-documented transient ischemic attack in a patient with "longstanding persistent AF" and on uninterrupted rivaroxaban, according to Di Biase.

Di Biase and his colleagues are "true believers in uninterrupted strategies on warfarin," he said, and helped the field move away from heparin bridging in ablation procedures. "Now everybody's doing it."

Swerdlow also observed that the group "was one of the first to teach us that we should do all cases on uninterrupted warfarin, and it's simplified our life[2]. It's made an enormous contribution to working electrophysiologists." And uninterrupted NOACs, he said, seem like the next step.

Di Biase reports consulting for Hansen Medical, Biosense Webster, and St Jude Medical and receiving honoraria for speaking or travel reimbursement from Biotronik, Atricure, and Epi EP. Swerdlow discloses receiving consulting fees or honoraria from Medtronic, St Jude Medical, and the Sorin Group; and serving on a speaker's bureau for and holding intellectual property rights with Medtronic.

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