Background: Amidst a looming worldwide heparin shortage, there are insufficient data to guide non-heparin based periprocedural anticoagulation in patients undergoing catheter ablation.
Objective: To report a multi-center series of left-sided catheter ablation of AF or PVC/VT performed using intravenous direct thrombin inhibitors (DTI) as an alternative to heparin.
Methods: We reviewed all catheter ablations at six institutions between 2006-19 to assess the safety and efficacy of DTIs for left-sided radiofrequency catheter ablation of atrial fibrillation (AF) and ventricular tachycardia (VT).
Results: In total 53 patients (age 63.0±9.3 years, 68% male, CHA₂DS₂-VASc score 2.8±1.6, LVEF 46±15%) underwent ablation with DTIs (75% bivalirudin, 25% argatroban) due to heparin contraindication(s) (72% heparin-induced thrombocytopenia, 21% heparin allergy, 4% protamine reaction, 4% religious reasons). The patient’s usual oral anticoagulant was continued without interruption in 69%. Procedures were performed for AF (64%) or VT / PVCs (36%). Transseptal puncture was undertaken in 81% and a contact force-sensing catheter used in 70%. Vascular ultrasound was used in 71% and femoral arterial access was gained in 36%. A bolus followed by infusion was used in all but 4 cases and Activated Clotting Time was measured peri-procedurally in 72%, with 32% receiving an additional bolus. Procedure duration was 216±116 minutes and ablation time 51±22 minutes. There were no major bleeding or embolic complications. Four patients had minor self-limiting bleeding complications including a small pericardial effusion (<1cm), small groin hematoma or hematuria.
Conclusion: In this small multi-center series, intravenous DTIs were safely used as an alternative to heparin for left-sided catheter ablation with a low risk of bleeding despite lack of a “reversal” agent.