Background: Thromboembolic stroke is a rare but devastating consequence of atrial fibrillation (AF) ablation. Utilization of intracardiac echocardiography (ICE) is a viable alternative to transesophageal echocardiography (TEE). However, majority of electrophysiologists still perform pre-ablation TEE even in patients that have been on continuous uninterrupted direct oral anticoagulants (DOACs).
Objective: To assess whether TEE is mandatory prior to AF ablation in patients undergoing ablation on uninterrupted DOACs.
Methods: Data from our prospective registry of AF patients undergoing radiofrequency catheter ablation on uninterrupted DOACs [apixaban, rivaroxaban, dabigatran and edoxaban] was analyzed. All patients included were on anticoagulation for at least four-weeks before ablation. All AF ablation procedures were performed under ICE guidance. Prior to performance of transseptal puncture, heparin bolus was administered, followed by continuous infusion, with a target activated clotting time over 300 seconds.
Results: A total of 6186 patients [3180 (51.4%): apixaban, 2528 (40.9%): rivaroxaban, 404 (6.5%): dabigatran, and 74 (1.2%): edoxaban] were analyzed. The mean age of the study population was 69.4 ± 10.3 years, of which 4194 (68%) patients were male and 5120 (83%) patients had non-paroxysmal AF. The mean CHA₂DS₂-VASc score was 2.9 ± 1.3; the mean CHADS₂ score was 1.7 ± 1.1. ICE ruled out left atrial appendage thrombus in all patients and revealed ‘smoke’ in 1672 (27%) patients. Transient ischemic attack was noted in one patient with long-standing persistent AF, in the setting of a missed dose of rivaroxaban prior to ablation.
Conclusion: Our study showed that performance of AF ablation in patients on uninterrupted DOACs without TEE is safe and feasible in high stroke-risk patients. These findings suggest that pre-ablation TEE should not be considered a customary approach for all patients undergoing AF ablation. Elimination of routine pre-ablation TEE would have significant economic and clinical implications.