Are you performing AF ablation procedures on therapeutic warfarin?
- Thu, 4/29/10 - 4:48pm
- 2 Comments
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The Heart Rhythm Society, the American Heart Association, and the American College of Cardiology have not yet come up with a consensus statement in regards to performing atrial fibrillation (AF) ablation procedures (including the transseptal component) on therapeutic anticoagulation. Several studies have reported success with this approach, but without any clear guidelines, I am interested in hearing how your labs are performing such procedures, including your results and complication rates.
Issues of interest include:
1) Are there any specific INR cut-offs at your institution for this procedure?
2) What are your target ACT values during the procedure?
3) Are there any specific issues related to the transseptal procedure and handling perforations?
4) Do you routinely use reversal agents at the end of the procedure?
5) Are there any changes in desheathing protocol in patients who are on therapeutic warfarin as compared to those who are not?
6) Please list any observed changes in outcomes with therapeutic warfarin (i.e., less neurologic events, more bleeds).
I welcome an open discussion and forum regarding this matter. Please feel free to respond in the comments section below.
Todd J. Cohen, MD is the Emeritus Editor In-Chief of EP Lab Digest. He serves as Director of Electrophysiology, Director of the Pacemaker-Arrhythmia Center, and Director of Advanced EP Technology and Innovations at Winthrop University Hospital in Mineola, New York. He is also an Associate Professor of Medicine at the State University of New York in Stony Brook. Look for his new blog next month on the Journal of Invasive Cardiology website (www.invasivecardiology.com).
Dr Cohen, our labs have been using this approach since 2003. The reason we adopted this approach was the higher incidence of bleeding and hematomas we observed using the Lovenex bridge approach.
Reply to this comment »1- The INR cut off level varies between on physician and the other in our labs but we also monitor the pt closely for INR 2-3 the week prior to the procedure.
2- ACT target 350 sec.
3- We have not encountered any specific problems during transseptal as a result.
4- We use Protamine 15-20 mg at the end of the procedure
5- We started to use this approach specifically for the observed hematomas in desheathing. Our studies showed no higher incidence of bleeding or hematomas using this approach
6- We definitely eliminated bleeding complications. We also believe that it is more convenient for the pt and less costly than Lovenox. Most importantly it offers more protections for persistent and long standing afibbers from CVA.
Salwa Beheiry, RN, CCRN
San Francisco, CA
Dr Cohen,
although it is not a routine for us to do left atrial ablations with therapeutic inr, we do most ablations with coumadin on board.
1. the inr cut off for us has been 3.0, although we have performed 2 cases safely with inr upto 3.2 after extensive discussion about the risk of bleed with the patient
2. act target 300.
3. no special issues about transeptal puncture. We give heparin after transeptal puncture. All transeptal punctures done under ICE guidance which ensures safety. No perforations have been noted in > 300 cases performed.
4. usual dose of protamine used at the end of the case is 40-50mg to reverse anticoagulation to achieve ACT < 200 before sheath removal. We have noted no increased incidence of hematoma with this process. In fact it has eliminated the need to restart heparin 6-8hr after the procedure and has infact reduced the incidence of bleed. We have noted the same trend for device implants and we routine perform device implants with therapeutic INR instead of stopping coumadin and then bridging with heparin.
5. no strokes have been noted in either approach. Certainly less bleed at the groin sites noted post procedure with doing procedure on coumadin therapy. Bleeding complication have been higher with heparin bridging. We do not used lovenox at our center.
Sambit Mondal, MD
Reply to this comment »Cardiac Electrophysiology
Via Christi Regional Medical Center.
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