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Optimal Management of Periprocedural Anticoagulation for Catheter Ablation of Atrial Fibrillation

Catheter ablation (CA) of atrial fibrillation (AF) is a safe procedure and the overall complication rates are low. Periprocedural thromboembolic events are one of the most feared complications of this procedure. A large systematic review of 192 studies showed the pooled complication rate of stroke or transient ischemic attacks was only  0.6%1. Despite the low rates of these thromboembolic complications, it is important to explore the factors that contribute to periprocedural thromboembolic events and more importantly ways to prevent them.

It turns out that the periprocedural anticoagulation (AC) strategy has a significant impact on the thromboembolic complications during CA of AF, and the peri-procedural management of AC has been continuously evolving. In the Vitamin K antagonist (VKA) era, the usual practice was to interrupt AC before ablation and then resume it after the procedure with the rationale of minimizing periprocedural bleeding. However, the pendulum moved rapidly after the landmark COMPARE trial. This study enrolled 1584 patients with CHADS2 score ≥1 and assigned them in 1:1 fashion to discontinue VKA or continue VKA during ablation and observed thromboembolic events in the 48 hours after ablation. The study showed that uninterrupted VKA use was associated with a reduction in periprocedural stroke and minor bleeding (odds ratio 13; 95% CI 3.1-55.6; p<0.001)2.

With the advent of direct oral anticoagulants (DOACS) and their improved efficacy in preventing thromboembolic events in patients with AF, an increasing number of patients in clinical practice are on DOACS when they present for CA. Multiple head-to-head trials have shown that uninterrupted DOACS are safe or even better as compared with uninterrupted VKA in preventing procedural thromboembolic events and current guidelines recommend uninterrupted or minimally interrupted DOACS for patients undergoing CA of AF3,4.

Currently, there is wide variability in clinical practice on whether to perform CA with completely uninterrupted DOAC or to omit a single dose or more than one dose? And is there any difference in procedural outcomes between these different strategies?

There is limited data on the comparison of procedural complications with different periprocedural AC strategies with DOACS. Data from randomized trials suggest that there is no difference in thromboembolic and bleeding outcomes whether uninterrupted, single-dose interruption, or more than one dose interruption strategy is used 5. One limitation to this data is that with the low rates of thromboembolic procedural complications in patients taking DOACS, it is hard to demonstrate that one strategy is better than the other. Silent cerebral ischemic lesions are increasingly recognized in patients undergoing CA and it is unclear if in the long term they are associated with dementia or cognitive impairment. An important finding from observational studies is that an uninterrupted DOAC strategy may be preventive against silent cerebral ischemic lesions, however, these results were not observed in randomized trials 6–8.

In summary, a strategy of uninterrupted or minimally interrupted DOACS appears to be safe in reducing periprocedural thromboembolic events for patients undergoing CA.

References

  1. Gupta Aakriti, Perera Tharani, Ganesan Anand, et al. Complications of Catheter Ablation of Atrial Fibrillation. Circ Arrhythm Electrophysiol. 2013;6(6):1082-1088. doi:10.1161/CIRCEP.113.000768
  2. Di Biase L, Burkhardt JD, Santangeli P, et al. 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. 2014;129(25):2638-2644. doi:10.1161/CIRCULATIONAHA.113.006426
  3. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 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 Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019;74(1):104-132. doi:10.1016/j.jacc.2019.01.011
  4. Romero Jorge, Cerrud-Rodriguez Roberto C., Alviz Isabella, et al. Significant Benefit of Uninterrupted DOACs Versus VKA During Catheter Ablation of Atrial Fibrillation. JACC Clin Electrophysiol. 2019;5(12):1396-1405. doi:10.1016/j.jacep.2019.08.010
  5. Jafry Ali H, Akhtar Khawaja H, Chaudhary Amna M, et al. Abstract 13721: Is Single Dose Interruption of Direct Oral Anticoagulants Necessary Before Atrial Fibrillation Ablation? A Systematic Review and Meta-analysis. Circulation. 2020;142(Suppl_3):A13721-A13721. doi:10.1161/circ.142.suppl_3.13721
  6. Müller P, Halbfass P, Szöllösi A, et al. Impact of periprocedural anticoagulation strategy on the incidence of new-onset silent cerebral events after radiofrequency catheter ablation of atrial fibrillation. J Interv Card Electrophysiol Int J Arrhythm Pacing. 2016;46(3):203-211. doi:10.1007/s10840-016-0117-6
  7. Nakamura K, Naito S, Sasaki T, et al. Uninterrupted vs. interrupted periprocedural direct oral anticoagulants for catheter ablation of atrial fibrillation: a prospective randomized single-center study on post-ablation thrombo-embolic and hemorrhagic events. EP Eur. 2019;21(2):259-267. doi:10.1093/europace/euy148
  8. Nakamura R, Okishige K, Shigeta T, et al. Clinical comparative study regarding interrupted and uninterrupted dabigatran therapy during perioperative periods of cryoballoon ablation for paroxysmal atrial fibrillation. J Cardiol. 2019;74(2):150-155. doi:10.1016/j.jjcc.2019.02.003

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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Is Routine Transesophageal Echocardiogram (TEE) Needed Before Atrial Fibrillation Ablation in Patients Treated with Uninterrupted Direct Oral Anticoagulation for At Least 3 Weeks?

What do the guidelines say?

The 2017 AF guidelines give a Class IIa recommendation for performing a transesophageal echocardiogram (TEE) for patients with AF undergoing ablation who are in AF on presentation, even if they have been receiving therapeutic anticoagulation for 3 weeks or longer1. However, the more recent 2020 European College of Cardiology AF guidelines recommend therapeutic oral anticoagulation for at least 3 weeks before ablation (Class 1), or, use of TEE to exclude left atrial appendage thrombus before ablation2.

What is routine clinical practice?

In accordance with the guidelines, many centers, including our own, perform routine TEE before AF ablation, however, my recent Twitter poll suggests that there is wide variation in clinical practice3 (Figure 1). The benefit of performing this TEE is the ability to rule out left atrial and left atrial appendage (LAA) thrombus. However, the routine use of TEE not only adds to the overall risk of the ablation but also increases the cost of care.

Why this practice should be questioned?

There have been multiple changes in recent years that have questioned the role of routine TEE before AF ablation. These include:

1) The advent of direct oral anticoagulants (DOACs) that have better efficacy and safety than warfarin.

2) Increasing preference and guideline recommendations endorsing the practice of uninterrupted DOACs before ablation that has shown to be associated with very low rates of peri-procedural thromboembolic complications.

3) Availability and use of intracardiac echocardiography (ICE) that can be used to rule out LAA thrombus.

What does recent data suggest? (Figure 2)

The September 2020 issue of Circulation Arrhythmia and Electrophysiology had a very interesting study by Diab et al asking this important clinical question4.  In their analysis of 900 patients presenting with AF or atrial flutter for ablation who did not undergo any pre-procedural or intraprocedural imaging for the purpose of ruling out LAA thrombus and were taking uninterrupted DOACs for > 3 weeks, they found that only 4 (0.3%) patients developed thromboembolic complications with 2 ischemic strokes, 1 transient ischemic attack (TIA) and 1 splenic infarct. The authors concluded that in patients taking uninterrupted DOACS and undergoing AF/atrial flutter ablation, omitting the pre-procedural TEE and ICE from the right ventricular outflow tract was feasible and associated with a low risk of thromboembolic complications.

Similar results were observed in the much large multicenter prospective registry data of over 6000 patients by Patel et al5 where only 1 TIA was observed in the setting of a missed dose of Rivaroxaban before ablation. However, in this study ICE ruled out LAA thrombi in all patients in contrast to the study by Diab et al where ICE was not used.

Take Home Message

Recent data from two large observational studies suggest that in patients with AF who are undergoing ablation and taking uninterrupted DOAC for at least > 3 weeks before ablation, performing a pre-procedural TEE is not necessary. Given the very low event rates of thromboembolic complications during ablation, the feasibility of a large randomized trial addressing this specific question seems uncertain as it will require a very large sample size.

Figure 1: Twitter poll showing the equipoise on performing routine transesophageal echocardiogram (TEE) in patients undergoing catheter ablation of atrial fibrillation.

Figure 2: Summary of data from 2 recent large observational studies suggesting that omitting routine transesophageal echocardiogram (TEE) is safe

 

REFERENCES

  1. Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2018;20(1):e1-e160. doi:10.1093/europace/eux274
  2. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J. Published online August 29, 2020. doi:10.1093/eurheartj/ehaa612
  3. Asad Z. Does your center perform “routine” TEE before AF ablation for patients taking uninterrupted oral anticoagulation for >3 weeks? https://twitter.com/ZainAsadEP/status/1347349701067206656?s=20
  4. Diab Mohamed, Wazni Oussama M., Saliba Walid I., et al. Ablation of Atrial Fibrillation Without Left Atrial Appendage Imaging in Patients Treated With Direct Oral Anticoagulants. Circulation: Arrhythmia and Electrophysiology. 2020;13(9):e008301. doi:10.1161/CIRCEP.119.008301
  5. Patel K, Natale A, Yang R, et al. Is transesophageal echocardiography necessary in patients undergoing ablation of atrial fibrillation on an uninterrupted direct oral anticoagulant regimen? Results from a prospective multicenter registry. Heart Rhythm. 2020;17(12):2093-2099. doi:10.1016/j.hrthm.2020.07.017

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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Building Your Brand: Research Career Planning and Scientific Writing

AHA 20 had a fantastic session titled “Building Your Brand” and it provided excellent insights on how to be a successful researcher in academic medicine. Panel participants Dr. Erin Michos, Dr. Louise McCullough, Dr. Andrew Landstrom, and Dr. Pradeep Natarajan shared their stories on how they got involved in research and the lessons they learned along the way. While the session focused on fellows in training, I will present my viewpoint on how these general principles are applicable to early-career physicians (ECP). Based on this session, I have developed a step by step approach.

When is the right time to get involved in research?

No doubt, it is good to start as early as possible, but it is never too late. Residency is the ideal time to get involved in the research. This head start allows you to explore different areas of research, find what interests you, and at the same time allows ample time to acquire skills needed to conduct research. For ECP, this means if you already started research during your training you are on the right track. If you were not exposed to much research during training, you can always start now.

Step#1: Start now.

How to get started?

The significance of finding the right mentor cannot be over-emphasized. It is important to meet different potential mentors and get to know them. This allows you to assess overlapping areas of interest, learn how research shaped their careers and most importantly get inspiration from their journey. For an ECP, it is important to work with different mentors that can develop you in different areas of research. These mentors can be across different institutions in the country.

Step#2: Find your mentoring team.

What skills are needed and how to acquire them?

“Writing” and “Statistics” are the two most important skills needed for any type of research. There are multiple ways to acquire these skills depending on how much time you want to invest. Most of these skills can be acquired by taking online classes or a degree program. Most academic programs offer classes in scientific writing, epidemiology, biostatistics, clinical trial design, and grant writing. For an ECP, if you think you will be doing research throughout your career, consider getting additional training through a master’s degree in clinical and translational sciences or in some cases a PhD.

Step#3: Acquire scientific writing and statistical skills.

What are the effective strategies for manuscript writing?

Writing the first draft is challenging but it is important to write it quickly and not worry about perfection. Start by writing the methods, followed by results, and leave an introduction and discussion to the end. Feedback from your mentor and collaborators will improve the paper.

Step#4: Write the first draft quickly, following this order: methods, results, introduction, discussion.

Quality or Quantity?

While it is ideal to always conduct high-quality and novel research projects, in-reality all such projects need research funding. Therefore, early in your research career, it is important to be productive and complete some less extensive projects starting from case reports, review articles, and retrospective studies. This allows you to practice the skills you acquired and get some confidence that you carried an idea from start to finish. It will build your research profile and make you a competitive candidate for grant funding in the future.

Step#5: Publish something even if it is a case report or a retrospective study.

How to build a brand?

Once you have found your mentoring team, acquired writing and statistical skills, and published at least one manuscript, it is time to develop a focus. You cannot build a brand without a focus. The first step is to find an area of research that you truly find fascinating and it typically includes ideas that you cannot stop thinking about and questions that give you an epiphany. Often, the most important research questions arise from your clinical work. Second, see if these ideas are vital from a clinical, research, and public health standpoint (significance). Third, see if you have the right environment (research team, institutional support, skills) needed to turn this idea into reality (feasibility). Often, we have to spend many years exploring different research interests and acquiring more skills (grantsmanship) before we arrive at an idea that we see ourselves developing into a brand (niche). For ECP, if you are busy clinicians with an interest in research, try your best to align your clinical interests with your research interests. Once you have established your niche, it is extremely important to stay focused so that all your time and energy is spent on developing your brand.

Step#6: Develop your niche, advance your skills, align clinical work with research, stay focused, avoid distractions.

What personality traits are needed?

A key trait is showing persistence despite multiple failures as it is not uncommon to have your first manuscript rejected by a journal or multiple journals. Having the persistence to learn from this experience, improve your manuscript and resubmit, is necessary. For mentees, it is important to develop a “can-do attitude”, be authentic, honest and follow through on commitments.

Step#7: Develop persistence, learn from failure, be a good mentee.

I hope you found these steps useful for building your brand in research. “The game has its ups and downs, but you can never lose focus of your individual goals and you can’t let yourself be beat because of lack of effort.” (Michael Jordan)

 

This session will be available on-demand until January 4th, 2020, and AHA Partners have FREE access to Scientific Sessions 2020 OnDemand Extended Access through 2021. 

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Developing Your Career as an Academic Physician

For all early-career physicians out there, I am sure you were not only looking for the latest in science at AHA 2020 but also some guidance on career development, and the session “Developing your Career as an Academic Physician” was just perfect.  Here I will review some of the fantastic talks from this session.

It started with “Pearls for Becoming an Academic Leader” by Dr. Jennifer S. Lawton, chief cardiac surgery at Johns Hopkins University, and offered the perfect blend of inspiration, encouragement, and advice on being an academic leader. I am sharing some pearls from this talk:

  • DECIDE: Decide if leadership is right for you and why you want to be a leader?
  • PREPARE: Prepare to be a leader (leadership books/courses), gain experience (program director, lab director, multidisciplinary teams, write protocols for your institution), learn time management for different roles (clinical, academic, leadership, mentorship), and build your credibility.
  • COMMUNICATE: Keep your CV updated and make it available at a moment’s notice and be ready to articulate your 5 and 10-year goals.
  • ATTACH: Attach yourself to mentors and learn from their success/failures and seek their advice regularly. Find sponsors who can open doors for you.
  • 70/20/10 Rule: Being an academic leader is 70% on the job training, 20% is learned from mentors/sponsors and 10% is formal leadership training.

The follow-up amazing talk was “What Really is Work-Life Balance” by Dr. Sasha Shillcutt, Tenured Professor of Anesthesiology at the University of Nebraska Medical Center. Loss of control over work is an important reason for burnout and this talk really re-framed my concept of Work-Life balance as it emphasized the concept that we are in the “driver’s seat” of our career. Two main concepts that were presented are:

  • Time Management Traps & Myths: Learn to say “No” to tasks that no longer interest you and success is directly linked to saying no.
  • Set Boundaries: Successful health care workers set boundaries that are intentional, efficient, and healthy. It takes practice and planning to set boundaries but they make your life easy.

“Maintaining Clinical Skills While Working in the Lab” is a challenge faced by physician-scientists and Dr. Emily MacKay from the University of Pennsylvania discussed some remarkable strategies for this.

  • Cognitive Reframing: The idea is to reframe your perspective about a challenge into an opportunity while the objective facts of the situation remain the same. For researchers that spend most of their time in the lab, make the most of your clinical time and develop “deliberate practice” where the focus is on quality, attention to detail, mindful and purposeful performance of procedures.
  • Context Switching: If you hit roadblocks with one problem where the solutions are not obvious you can physically distance yourself from the problem, and then come back to it later and this will help you find a solution.
  • Handling Commitment: Using the Eisenhower matrix to identify tasks that are urgent and important and need to be handled quickly vs tasks are urgent but not important and can be delegated or tasks that are important but not urgent and can be scheduled.

I will encourage all early careers to watch this session and take notes as it is full of pearls for career development.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Late-Breaking Highlights: “To Screen Or Not To Screen And Then What? Studies of Detection and Treatment of AF”

This was an exciting session at AHA 2020 which focused on clinical trials of screening, monitoring, and early intervention in Atrial Fibrillation (AF). Screening of AF is a controversial topic and for individuals >65 years, current AHA guidelines give a Grade 2a recommendation for screening whereas USPSTF guidelines suggest that there is insufficient evidence for screening. In this article, I will be discussing studies that addressed AF screening and their implications on clinical practice with Dr. Stavros Stavrakis who is an electrophysiologist and Associate Professor at the University of Oklahoma Health Sciences Center, Oklahoma City.

Question: What are the important goals when we think about screening for AF?

Dr. Stavrakis: The important goals for screening in AF are to establish a diagnosis of new AF in patients at high risk of stroke so they can be anticoagulated, ultimately reducing the risk of stroke.

There were 3 important trials that addressed AF screening in different patient populations.

SEARCH AF

  • In patients who have undergone cardiac surgery and have a higher risk of stroke but no history of pre-operative or pre-discharge AF, what is the risk of developing AF/Aflutter in the sub-acute post discharge period?
  • 336 post-cardiac surgery patients (median CHADS2Vasc Score 4) but with little or no AF in the post-operative period (<24 hours of AF but no intent to anticoagulate at discharge) were randomized to continuous cardiac rhythm monitoring vs usual care during the sub-acute post discharge period.
  • In the enhanced cardiac rhythm monitoring group 19.6% participants developed AF/Aflutter as compared with 1.7% in the usual care group with an absolute rate difference 17.9% (p<0.001, NNS=6).

Question: What are the implications of this trial on clinical practice?

Dr. Stavrakis: Risk of POAF, although peaking at 48-72hours post-op, is not confined to the index hospitalization, continuous monitoring for POAF can identify AF in a significant proportion of patients (20%) that may need treatment with anticoagulation. Whether anticoagulation improves outcomes in these patients, remains to be determined.

VITAL-AF Trial

  • Among older adults (age>65) presenting to primary care visits, does point of care rhythm assessment with a single lead ECG result in increased diagnosis of AF?
  • 30,722 patients were randomized to screening vs control.
  • Screening did not significantly affect AF diagnosis in the overall study sample (1.74% vs 1.60%, p=0.33)
  • Increased likelihood of AF diagnosis at primary care encounter (p<0.02)
  • Effectiveness of screening varied by age with effective screening in age>85 (risk difference 1.88%, NNS=53)
  • Overall no difference in the initiation of anticoagulation

Question: What are the implications of this trial on clinical practice?

Dr. Stavrakis: There are 2 important implications from this trial.

  1. Screening everyone age>65 for AF at a single time point is not an efficient way to detect AF, especially if the usual care is very good in detecting AF by pulse palpation or BP device.Screening at age>85 may be more effective than usual care to identify silent AF, but it is uncertain if it changes management or outcomes

mSTOPS

  • Can screening for AF by wearing an ECG patch improve clinical outcomes at 3-years?
  • 1718 actively monitored participants vs 3371 matched observational controls with analysis of 3-year clinical outcomes.
  • Mean duration of follow-up was 29 months
  • 11.4% of actively monitored patients developed AF vs 7.3% of matched controls
  • No difference in anticoagulation prescription between both arms (45.2% vs 44%, p=0.84)
  • 3-year Primary combined end point (death, stroke, systemic embolism or MI) for entire cohort was 4.5 vs 5.5 per 100 person-year (HR 0.79, p<0.01) and for diagnosed AF patients it was 8.4 vs 13.8 per 100 person-year (HR 0.53, p<0.01).

Question: What are the implications of this trial on clinical practice?

Dr. Stavrakis: Clinical outcomes can be improved with AF screening provided these patients are followed up for extended periods of time. However, this was not a randomized trial and unknown confounders may have influenced the outcome.

Question: What are 3 important unanswered questions pertinent to screening of AF?

  1. What is the impact of AF screening on clinical outcomes? Large studies, adequately powered to detect clinical outcomes, are underway (SAFER, HEARTLINE, GUARD-AF).
  2. What is the optimal screening intensity that identifies AF which would benefit from anticoagulation?
  3. What is the minimum AF burden that, if identified with screening, would benefit from anticoagulation?

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”