Consensus document on antithrombotic therapy in the setting of electrophysiological procedures

Abstract

Guidelines and Expert Consensus documents are proposed to help physicians to select the best possible diagnostic or therapeutic strategies for an individual patient with a specific disease. Recommendations issued from these documents are based on an extensive review of the literature and on discussions among experts when hard data are incomplete or missing. It has been shown that patient outcomes improve when guidelines recommendations are applied in clinical practice. Publication and promotion of these guidelines is one of the most important tasks of scientific societies. The recently created European Heart Rhythm Association (EHRA) wants to meet this commitment in its specific field of competence and one assignment of the scientific committee of EHRA is to propose and promote Guidelines in the management of heart rhythm disturbances not already covered by the European Society of Cardiology (ESC). Electrophysiological studies (EPSs), whether or not associated with therapeutic procedures (ablation using different sources of energy or reduction of tachycardia), show the percutaneous introduction of one or multiple catheters to record the electrical activity of the heart or to pace its different cavities. The introduction and manipulation of these catheters in arteries, veins, or cardiac cavities have multiple pathophysiological consequences and one of the most evident is to activate the coagulation cascade with the risk to induce new clots or to mobilize pre-existing ones. Furthermore, withdrawal of catheters induces haemorrhage usually limited by the compression of the site of venous or arterial puncture. There is also a close relationship between EPS and thrombus formation (thrombogenesis) and thus, rhythmologists need to balance the risks between thrombo-embolism and bleeding. There are no guidelines on the use of antithrombotic therapies in the setting (before, during, and after) of EPS. Generally, different laboratories have their own approaches to this clinical problem. The aim of the present document is to propose consensus recommendations written according to the ‘Guidelines for guidelines’ published by the Guidelines committee of the ESC. It should be stressed that this topic has been poorly studied in clinical trials and that very few well-designed studies are at our disposal to guide evidence-based management. This is a major limitation to give hard recommendations and explains why the level of recommendation in most instances is Grade C (‘expert opinion’). The present document has been divided into five main sections: the first three deals with the general risks of thrombo-embolism or bleeding, whereas the fourth section relates more to the risks of venous or arterial access and the last section relates to some special situations. The division between low-, intermediate-, and high-risk procedures for thrombo-embolism or bleeding is partly arbitrary, as a ‘low-risk’ intervention in a high-risk patient becomes an intermediate-risk procedure. Even with these limitations, such a division could be helpful for readers. It is the hope of the task force that this document will prompt well-designed trials that would hopefully strengthen the impact of the following recommendations. Radiofrequency (RF) catheter ablation, because of its curative nature and high success and low complication rates, has become the treatment of choice for a wide variety of arrhythmias. Indications have recently expanded to include even complex arrhythmias such as atrial fibrillation (AF), atrial flutter (AFL), and ventricular tachycardia (VT) associated with structural heart disease. A recent review indicates an overall low incidence of 0.6% of reported thrombo-embolic complications; the risk was increased when an ablation procedure was performed in the left heart (1.6–2.8%). 1–3 In an earlier survey, 2 the reported procedure-related complications of RF ablation occur in ∼5.1%. The risk is also high when the ablation procedure is performed in the left heart (1.8–2%) and for VT (2.8%). 3 Non-pharmacological measures play an increasing role in AF management and, in many instances, offer the possibility of a ‘cure’. 4 However, AF recurrence rates with catheter ablation techniques are significant. 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proposed a of that to thrombus of the and The of thrombo-embolism is increasing to the of in the of an procedure to a or In the setting of complex catheter ablation thrombo-embolic complications most from the of of an example, in AF ablation, include a reduction in the to a on the of coagulation and and However, this be an as from major arteries, from and in the of the have been shown to give to of are into catheter withdrawal and be into the by or catheter in the with an catheter or also be thrombus be into the by a by a in by the of electrical or by catheter manipulation or as or catheter In the clinical setting multiple usually a is to or these of rhythm by ablation in of in with whereas in with catheter ablation in ablation of has been associated with and the of more the left is by atrial that of AF to It has been reported with of of RF in reduction of and There is to that this is for an increased risk of thrombo-embolism for to of AF in to rhythm and in a in the risk of The for 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physicians following RF However, the of this has not been RF is performed atrial following to rhythm thrombo-embolic complications and, should at be of atrial is a of of AF and the heart disease. 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