How minimally interrupted direct oral anticoagulants affect intraprocedural anticoagulation during atrial fibrillation ablation? Insights from a Japanese single-center retrospective study

Background: Data are still lacking regarding the effects of minimally interrupted direct oral anticoagulants (MID) on the intensity of intraprocedural anticoagulation of atrial fibrillation (AF) ablation.

Methods: A total of consecutive 269 patients who undergone AF ablation were eligible for the study. All oral anticoagulants (OACs) were discontinued just one dose before the procedure except warfarin. We assessed the total required dose of UFH and time-to-target ACT > 300 seconds (TTA) for each of direct oral anticoagulant (DOAC) groups compared with the uninterrupted warfarin group.

Results: DOACs were used in 86% of the patients in the present study (dabigatran group (DG)-17%, rivaroxaban group (RG)-30%, apixaban group (AG)-29%, and edoxaban group (EG)-10%). DG and EG used comparable dose of total UFH to WG (WG vs DG; 206 ± 53 U/kg vs 231 ± 63 U/kg; P = .664, vs EG; 239 ± 67 U/kg; P = .335), while RG and AG required higher total UFH (WG vs RG; 206 ± 53 U/kg vs 270 ± 63 U/kg; P < .001, vs AG; 263 ± 62 U/kg; P < .001). TTA was significantly longer in RG (RG:73 ± 28 minutes vs WG:51 ± 25 minutes; P = .001), AG (AG:64 ± 26 minutes vs WG:51 ± 25 minutes; P = .02), and EG (EG:67 ± 34 minutes vs WG:51 ± 25 minutes; P = .02) than WG, whereas DG was comparable to WG (DG:51 ± 29 minutes vs WG:51 ± 25 minutes; P = NS). Especially, only RG demonstrated significantly slower increase in ACT than WG (P = .013). In the multivariate analysis, warfarin or dabigatran use, age > 75 years, and body weight < 60 kg are clinical predictors for achieving TTA within 60 minutes (TTA-60).

Conclusion: MID-dabigatran was comparable to uninterrupted warfarin, whereas MID-factor Xa inhibitors were not. MID is a feasible protocol; however, we should be aware of its effect on the intraprocedural anticoagulation and differences among DOACs in the responsiveness to heparin.