Published Online
on November 12, 2007

A more recent version of this article appeared on November 27, 2007

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Submitted on July 12, 2007
Accepted on September 14, 2007

Atrial Fibrillation Ablation in Patients With Therapeutic International Normalized Ratio: Comparison of Strategies of Anticoagulation Management in the Periprocedural Period

Oussama M. Wazni MD, Salwa Beheiry RN, Tamer Fahmy MD, Conor Barrett MD, Steven Hao MD, Dimpi Patel DO, Luigi Di Biase MD, David O. Martin MD, MPH, Mohamed Kanj MD, Mauricio Arruda MD, Jennifer Cummings MD, Robert Schweikert MD, Walid Saliba MD, and Andrea Natale MD^*

From The Center for Atrial Fibrillation (O.M.W., T.F., C.B., D.P., L.D.B., D.O.M., M.K., M.A., J.C., R.S., W.S., A.N.), The Cleveland Clinic, Cleveland, Ohio, and Sutter Pacific Heart Centers (S.B., S.H.), San Francisco, Calif. Dr Natale currently is affiliated with Stanford University, Palo Alto, Calif.

^* To whom correspondence should be addressed. E-mail: nataleam{at}roadrunner.com.

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.

Key words: ablation • fibrillation • atrium • coagulation

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