Table 4.
Anticoagulation strategies: pre-, during, and postcatheter ablation of AF
| Recommendation | Class | LOE | References | |
|---|---|---|---|---|
| Preablation | For patients undergoing AF catheter ablation who have been therapeutically anticoagulated with warfarin or dabigatran, performance of the ablation procedure without interruption of warfarin or dabigatran is recommended. | I | A | [366–373] |
| For patients undergoing AF catheter ablation who have been therapeutically anticoagulated with rivaroxaban, performance of the ablation procedure without interruption of rivaroxaban is recommended. | I | B-R | [374] | |
| For patients undergoing AF catheter ablation who have been therapeutically anticoagulated with a NOAC other than dabigatran or rivaroxaban, performance of the ablation procedure without withholding a NOAC dose is reasonable. | IIa | B-NR | [375] | |
| Anticoagulation guidelines that pertain to cardioversion of AF should be adhered to in patients who present for an AF catheter ablation procedure. | I | B-NR | [5, 6] | |
| For patients anticoagulated with a NOAC prior to AF catheter ablation, it is reasonable to hold one to two doses of the NOAC prior to AF ablation with reinitiation postablation. | IIa | B-NR | [372, 376–380] | |
| Performance of a TEE in patients who are in AF on presentation for AF catheter ablation and who have been receiving anticoagulation therapeutically for 3 weeks or longer is reasonable. | IIa | C-EO | [5, 6] | |
| Performance of a TEE in patients who present for ablation in sinus rhythm and who have not been anticoagulated prior to catheter ablation is reasonable. | IIa | C-EO | [5, 6] | |
| Use of intracardiac echocardiography to screen for atrial thrombi in patients who cannot undergo TEE may be considered. | IIb | C-EO | [381–386] | |
| During ablation | Heparin should be administered prior to or immediately following transseptal puncture during AF catheter ablation procedures and adjusted to achieve and maintain an ACT of at least 300 s. | I | B-NR | [369, 380–382, 387–393] |
| Administration of protamine following AF catheter ablation to reverse heparin is reasonable. | IIa | B-NR | [394] | |
| Postablation | In patients who are not therapeutically anticoagulated prior to catheter ablation of AF and in whom warfarin will be used for anticoagulation postablation, low molecular weight heparin or intravenous heparin should be used as a bridge for initiation of systemic anticoagulation with warfarin following AF ablation.∗ | I | C-EO | |
| Systemic anticoagulation with warfarin∗or a NOAC is recommended for at least 2 months postcatheter ablation of AF. | I | C-EO | [1, 2] | |
| Adherence to AF anticoagulation guidelines is recommended for patients who have undergone an AF ablation procedure, regardless of the apparent success or failure of the procedure. | I | C-EO | [5, 6] | |
| Decisions regarding continuation of systemic anticoagulation more than 2 months post ablation should be based on the patient's stroke risk profile and not on the perceived success or failure of the ablation procedure. | I | C-EO | [5, 6] | |
| In patients who have not been anticoagulated prior to catheter ablation of AF or in whom anticoagulation with a NOAC or warfarin has been interrupted prior to ablation, administration of a NOAC 3 to 5 h after achievement of hemostasis is reasonable postablation. | IIa | C-EO | [372, 376–380] | |
| Patients in whom discontinuation of anticoagulation is being considered based on patient values and preferences should consider undergoing continuous or frequent ECG monitoring to screen for AF recurrence. | IIb | C-EO |
AF atrial fibrillation, LOE Level of Evidence, NOAC novel oral anticoagulant, TEE transesophageal electrocardiogram, ACT activated clotting time
∗Time in therapeutic range (TTR) should be > 65% – 70% on warfarin