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DOI: 10.1055/s-0032-1332464
Under which conditions is it justified to stop oral anticoagulation after surgical ablation and Event Recorder Implantation?
Objectives: The benefit of atrial fibrillation (AF) surgery remains unclear as long as patients have to continue anticoagulation even after successful conversion to stable sinus rhythm (SR). We analyzed our ablation success rate and patient data based on risk scores predicting risk of thromboembolic or bleeding complications, thus trying to develop new recommendations for postoperative anticoagulation.
Methods: We implanted Event Recorders in fifty consecutive patients undergoing AF ablation concomitant to open heart surgery. Ablation was performed either by left atrial or biatrial ablation. Data of the Event Recorders were obtained via telemonitoring at one-month-intervals postoperatively. Of 50 patients, 22 were eligible for analysis of 3-months-follow-up data. Success rate, defined as AF-burden ≤0.5%, CHA2DS2-VASc- and HASBLED-Score were calculated.
Results: Mean age was 71 ± 8 years. Of 50 procedures, 22 (44%) were single and 28 (56%) combined procedures. Mean diameter of left atrium (LA) was 49 mm (range 38 – 70 mm); AF duration-time was less than 2 years in 60%, up to 5 years in 16% and more than 5 years in 24%. Of 22 patients with data at 3-month-follow up, 3/22 (14%) had paroxysmal AF, 8/22 (36%) persistent and 11/22 (50%) longstanding-persistent AF. Of patients with paroxysmal AF, 100% (3/3) were responders with an AF-burden of less than 0.5% after three months. 62% (5/8) of patients with persisting AF and 36% (4/11) of patients with longstanding-persistent were responders. Significant predictor for ablation success was SR on discharge (p = 0.02). CHA2DS2-VASc-Score was 3.8 ± 1.8 on average; 5/50 patients (11%) had a score of less than 2, all other patients (45/50, 89%) had a score between 2 and 7 and therefore a high risk of systemic thromboembolism. HASBLED Score was above 3, predicting a high risk of bleeding in 52% (26/50).
Conclusion: We therefore propose a new approach to postoperative anticoagulation: in patients with previous paroxysmal AF, SR on discharge and a low thromboembolic risk, oral coagulation should be discontinued. Patients with longstanding-persistent AF and high thromboembolic risk still require anticoagulation. In patients with persistent AF, risk factors and positive predictors such as SR on discharge should be evaluated before deciding for or against anticoagulation. Particularly in these patients, Event Recorder monitoring is a helpful guidant.