Atrial fibrillation ablation in patients with therapeutic international normalized ratio: Comparison of strategies of anticoagulation management in the periprocedural period

BACKGROUND - The best approach to management of anticoagulation before and after atrial fibrillation ablation is not known. METHODS AND RESULTS - We compared outcomes in consecutive patients undergoing pulmonary vein antrum isolation for persistent atrial fibrillation. Early in our practice, warfarin was stopped 3 days before ablation, and a transesophageal echocardiogram was performed to rule out clot. Enoxaparin, initially 1 mg/kg twice daily (group 1) and then 0.5 mg/kg twice daily (group 2), was used to "bridge" patients after ablation. Subsequently, warfarin was continued to maintain the international normalized ratio between 2 and 3.5 (group 3). Minor bleeding was defined as hematoma that did not require intervention. Major bleeding was defined as either cardiac tamponade, hematoma that required intervention, or bleeding that required blood transfusion. Pulmonary vein ablation was performed in 355 patients (group 1=105, group 2=100, and group 3=150). More patients had spontaneous echocardiographic contrast in groups 1 and 2. One patient in group 1 had an ischemic stroke compared with 2 patients in group 2 and no patients in group 3. In group 1, 23 patients had minor bleeding, 9 had major bleeding, and 1 had pericardial effusion but no tamponade. In group 2, 19 patients had minor bleeding, and 2 patients developed symptomatic pericardial effusion with need for pericardiocentesis 1 week after discharge. In group 3, 8 patients developed minor bleeding, and 1 patient developed pericardial effusion with no tamponade. CONCLUSIONS - Continuation of warfarin throughout pulmonary vein ablation without administration of enoxaparin is safe and efficacious. This strategy can be an alternative to bridging with enoxaparin or heparin in the periprocedural period.