(AF) is a highly prevalent chronic condition and a growing number of patients
are on chronic anticoagulation therapy with novel oral anticoagulant (NOAC) agents:
dabigatran, rivaroxaban, and apixaban. Many of these patients are expected to
require invasive procedures. There is no clear consensus regarding the peri-procedural
management of patients using NOACs, as to how to minimize both bleeding risk
and thromboembolism risk. This review of the current available literature is designed
to help formulate peri-procedural anticoagulation strategies for patients with
AF taking NOACs who are being considered for catheter ablation, device implant,
or other surgery.
To help frame
the discussion, we offer 3 case vignettes that we will revisit to at the end of
the review of the existing literature.
Case 1: A 62
year-old female with hypertension, diabetes, and symptomatic paroxysmal AF who
is prescribed dabigatran for thromboembolism prevention. She has failed
attempts at maintaining sinus rhythm with antiarrhythmic drugs. She is now
being considered for catheter ablation of AF.
Case 2: A 76 year-old
male with hypertension, diabetes, prior stroke, and ischemic cardiomyopathy who
has persistent drug-refractory AF. He is maintained on chronic anticoagulation
with dabigatran for thromboembolism prevention. He has an implantable
cardioverter-defibrillator (ICD) which requires a generator change.
Case 3: A 58 year-old
male with hypertension and paroxysmal AF who takes rivaroxaban for
thromboembolic prophylaxis and is being considered for a knee replacement
Credits: Siva Krothapalli; Prashant Bhave