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Heart and Vessels

, Volume 34, Issue 5, pp 832–841 | Cite as

A novel protocol for initial heparin administration during catheter ablation for atrial fibrillation in patients taking direct oral anticoagulants

  • Hideyuki KishimaEmail author
  • Takanao Mine
  • Eiji Fukuhara
  • Kenki Ashida
  • Masaharu Ishihara
  • Tohru Masuyama
Original Article
  • 124 Downloads

Abstract

Thromboembolism and bleeding complications remain a major limitation of the catheter ablation (CA) for atrial fibrillation (AF). This study aimed to evaluate the association between achieving target activated clotting time (ACT) and clinical factors, and to develop an appropriate protocol for early achievement of target ACT in patients with direct oral anticoagulants (DOACs). At the initiation cohort, 190 patients (127 males, age 68 ± 9) taking DOACs who underwent CA for AF were studied. All patients underwent transthoracic echocardiography/transesophageal echocardiography/blood sampling before the CA. The ACTs were measured before heparin administration (pre-ACT) and in 30 min (30-min ACT) after initial heparin administration (100 U/kg +3000 U). At the validation cohort, the indicator obtained from the first study was reassessed in the subsequent 138 patients (94 males, age 68 ± 10). At the initiation cohort, 30-min ACT reached the target ACT in 79/190 patients (42%). Univariate analysis showed that longer pre-ACT, elevated aPTT, higher PT-INR, antiplatelet medication, and dabigatran were associated with achieving the target 30-min ACT. On multivariate analysis, only longer pre-ACT was independently associated with achieving the target 30-min ACT (P = 0.0396, the optimal cutoff value; 130 s). As a novel protocol, we added 2000 U of initial heparin dose (total 100 U/kg +5000 U) in patients with low pre-ACT (< 130); then, the achievement rate to target 30-min ACT improved from 41.6 to 80.5% without increasing bleeding complications. Our novel protocol of initial heparin administration based on pre-ACT is useful for an appropriate systemic anticoagulation in patients taking DOACs during the CA for AF.

Keywords

Direct oral anticoagulants Heparin Atrial fibrillation Catheter ablation 

Notes

Funding

No funding was received for the study.

Conflict of interest

There are no conflicts of interest on the part of authors.

References

  1. 1.
    Di Biase L, Burkhardt JD, Santangeli P, Mohanty P, Sanchez JE, Horton R, Gallinghouse GJ, Themistoclakis S, Rossillo A, Lakkireddy D, Reddy M, Hao S, Hongo R, Beheiry S, Zagrodzky J, Rong B, Mohanty S, Elayi CS, Forleo G, Pelargonio G, Narducci ML, Dello Russo A, Casella M, Fassini G, Tondo C, Schweikert RA, Natale A (2014) Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the role of coumadin in preventing thromboembolism in atrial fibrillation (AF) patients undergoing catheter ablation (COMPARE) randomized trial. Circulation 129:2638–2644CrossRefGoogle Scholar
  2. 2.
    Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A (2005) Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation 111:1100–1105CrossRefGoogle Scholar
  3. 3.
    Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, d’Avila A, de Groot NMSN, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T (2017) 2017 HRS/EHRA/ECAS/ APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 14:e275–e444CrossRefGoogle Scholar
  4. 4.
    Mani H, Lindhoff-Last E (2014) New oral anticoagulants in patients with nonvalvular atrial fibrillation: a review of pharmacokinetics, safety, efficacy, quality of life, and cost effectiveness. Drug Des Dev Ther 8:789–798CrossRefGoogle Scholar
  5. 5.
    Nagao T, Inden Y, Yanagisawa S, Kato H, Ishikawa S, Okumura S, Mizutani Y, Ito T, Yamamoto T, Yoshida N, Hirai M, Murohara T (2015) Differences in activated clotting time among uninterrupted anticoagulants during the periprocedural period of atrial fibrillation ablation. Heart Rhythm 12:1972–1978CrossRefGoogle Scholar
  6. 6.
    Armbruster HL, Lindsley JP, Moranville MP, Habibi M, Khurram IM, Spragg DD, Berger RD, Calkins H, Marine JE (2015) Safety of novel oral anticoagulants compared with uninterrupted warfarin for catheter ablation of atrial fibrillation. Ann Pharmacother 49:278–284CrossRefGoogle Scholar
  7. 7.
    Kishima H, Mine T, Takahashi S, Ashida K, Ishihara M, Masuyama T (2016) The impact of elevated left atrial pressure in sinus rhythm after cardioversion on outcomes after catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol 27:813–819CrossRefGoogle Scholar
  8. 8.
    Youden WJ (1950) Index for rating diagnostic tests. Cancer 3:32–35CrossRefGoogle Scholar
  9. 9.
    Marrouche NF, Brachmann J, Andresen D, Siebels J, Boersma L, Jordaens L, Merkely B, Pokushalov E, Sanders P, Proff J, Schunkert H, Christ H, Vogt J, Bänsch D, Investigators CASTLE-AF (2018) Catheter ablation for atrial fibrillation with heart failure. N Engl J Med 378:417–427CrossRefGoogle Scholar
  10. 10.
    January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW, ACC, AHA Task Force Members (2014) 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 130:e199–e267Google Scholar
  11. 11.
    Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GY, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K (2016) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 18:1609–1678CrossRefGoogle Scholar
  12. 12.
    DeVille JB, Svinarich JT, Dan D, Wickliffe A, Kantipudi C, Lim HW, Plummer L, Baker J, Kowalski M, Baydoun H, Jenkins M, Chang-Sing P (2014) Comparison of resource utilization of pulmonary vein isolation: cryoablation versus RF ablation with three-dimensional mapping in the Value PVI Study. J Invasive Cardiol 26:268–272Google Scholar
  13. 13.
    Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN Shemin RJ, Heart Rhythm Society, European Heart Rhythm Association, European Cardiac Arrhythmia Society, American College of Cardiology, American Heart Association, Society of Thoracic Surgeons (2007) HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation developed in partnership with the European Heart Rhythm Association (EHRA) and the European Cardiac Arrhythmia Society (ECAS); in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Endorsed and approved by the governing bodies of the American College of Cardiology, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, and the Heart Rhythm Society. Europace 9:335–379Google Scholar
  14. 14.
    Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L, Committees ARISTOTLE, Investigators (2011) Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 365:981–992CrossRefGoogle Scholar
  15. 15.
    Miller CS, Grandi SM, Shimony A, Filion KB, Eisenberg MJ (2012) Meta-analysis of efficacy and safety of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus warfarin in patients with atrial fibrillation. Am J Cardiol 110:4534–4560CrossRefGoogle Scholar
  16. 16.
    Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC, Nessel CC, Paolini JF, Berkowitz SD, Fox KA, Califf RM, Investigators ROCKETAF (2011) Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 365:883–891CrossRefGoogle Scholar
  17. 17.
    Yamaji H, Murakami T, Hina K, Higashiya S, Kawamura H, Murakami M, Kamikawa S, Hirohata S, Kusachi S (2018) Differences in activated clotting time and initial heparin dosage during atrial fibrillation ablation for patients with edoxaban compared with warfarin. J Cardiovasc Electrophysiol 29:835–843CrossRefGoogle Scholar
  18. 18.
    Yamaji H, Murakami T, Hina K, Higashiya S, Kawamura H, Murakami M, Kamikawa S, Komtasubara I, Kusachi S (2016) Adequate initial heparin dosage for atrial fibrillation ablation in patients receiving non-vitamin k antagonist oral anticoagulants. Clin Drug Investig 36:837–848CrossRefGoogle Scholar
  19. 19.
    Wazni OM, Beheiry S, Fahmy T, Barrett C, Hao S, Patel D, Di Biase L, Martin DO, Kanj M, Arruda M, Cummings J, Schweikert R, Saliba W, Natale A (2007) Atrial fibrillation ablation in patients with therapeutic international normalized ratio: comparison of strategies of anticoagulation management in the periprocedural period. Circulation 116:2531–2534CrossRefGoogle Scholar
  20. 20.
    Gautam S, John RM, Stevenson WG, Jain R, Epstein LM, Tedrow U, Koplan BA, McClennen S, Michaud GF (2011) Effect of therapeutic INR on activated clotting times, heparin dosage, and bleeding risk during ablation of atrial fibrillation. J Cardiovasc Electrophysiol 22:248–254CrossRefGoogle Scholar
  21. 21.
    Wu S, Yang YM, Zhu J, Wan HB, Wang J, Zhang H, Shao XH (2016) Metaanalysis of efficacy and safety of new oral anticoagulants compared with uninterrupted vitamin K antagonists in patients undergoing catheter ablation for atrial fibrillation. Am J Cardiol 117:926–934CrossRefGoogle Scholar
  22. 22.
    Hattersley PG (1966) Activated coagulation time of whole blood. JAMA 196:436–440CrossRefGoogle Scholar
  23. 23.
    Otuki S, Izumi D, Suda M, Sato A, Hasegawa Y, Yagihara N, Iijima K, Chinushi M, Fuse I, Minamino T (2018) Effects of direct oral anticoagulants at the peak phase, trough phase, and after vascular injury. J Am Coll Cardiol 71:102–104CrossRefGoogle Scholar

Copyright information

© Springer Japan KK, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Cardiovascular Division, Department of Internal MedicineHyogo College of MedicineNishinomiyaJapan

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