Skip to main content
SpringerLink
Log in

Apixaban for periprocedural anticoagulation during catheter ablation of atrial fibrillation: a systematic review and meta-analysis of 1691 patients

  • REVIEWS
  • Published:
Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

    We’re sorry, something doesn't seem to be working properly.

    Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

Abstract

Purpose

Apixaban, a direct factor Xa inhibitor recently approved for thromboembolic prophylaxis in patients with nonvalvular atrial fibrillation (AF), is increasingly used in patients undergoing catheter ablation of AF. However, large randomized studies supporting its use in the ablation context are still lacking. We undertook the present meta-analysis to assess the impact of apixaban in terms of thromboembolic and bleeding events in patients undergoing AF ablation as compared to warfarin.

Methods

MEDLINE/PubMed, Cochrane Library, and references reporting AF ablation and apixaban were screened and studies included if matching inclusion and exclusion criteria.

Results

One randomized and five nonrandomized studies were included in the analysis. Patients enrolled were 1691 patients (668 on apixaban and 1023 on warfarin). There was no heterogeneity in all the outcome comparisons. No deaths were reported. We did not observe any difference between apixaban and warfarin with respect to thromboembolic events (OR = 1.10, 95 % CI 0.24–5.16), major bleedings (OR = 1.56, 95 % CI 0.59–4.13), cardiac tamponade (OR 1.69, 95 % CI 0.52–5.54), minor bleedings (OR 0.96, 95 % CI 0.58–1.59), and the composite endpoint of death, thromboembolic events, and bleedings (OR 1.03, 95 % CI 0.65–1.64).

Conclusions

The rates of death, thromboembolic events, major bleedings including cardiac tamponade, and minor bleedings in patients on apixaban undergoing AF ablation are very low and similar to that seen in patients treated with uninterrupted warfarin. Although primary driven by nonrandomized studies, these results support apixaban as periprocedural anticoagulation during AF ablation procedures.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

AF:

Atrial fibrillation

PV:

Pulmonary vein

PVI:

Pulmonary vein isolation

CA:

Catheter ablation

LA:

Left atrium

LVEF:

Left ventricular ejection fraction

NOACs:

Novel oral anticoagulants

VKA:

Vitamin K antagonist

TIA:

Transient ischemic attack

ACT:

Activated clotting time

INR:

International normalized ratio

ICE:

Intracardiac echocardiography

AADs:

Antiarrhythmic drugs

LMWH:

Low-molecular-weight heparin

MRI:

Magnetic resonance imaging

CT:

Computerized tomography

SCE:

Silent cerebrovascular event

ES:

Effect size

References

  1. Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004;110(9):1042–6.

    Article  PubMed  Google Scholar 

  2. Chen LY, Shen WK. Epidemiology of atrial fibrillation: a current perspective. Heart Rhythm. 2007;4(3 Suppl):S1–6.

    Article  PubMed  Google Scholar 

  3. Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace. 2012;14(4):528–606.

    Article  PubMed  Google Scholar 

  4. Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3(1):32–8.

    Article  PubMed  Google Scholar 

  5. Spragg DD, Dalal D, Cheema A, Scherr D, Chilukuri K, Cheng A, et al. Complications of catheter ablation for atrial fibrillation: incidence and predictors. J Cardiovasc Electrophysiol. 2008;19(6):627–31.

    Article  PubMed  Google Scholar 

  6. Dorbala S, Cohen AJ, Hutchinson LA, Menchavez-Tan E, Steinberg JS. Does radiofrequency ablation induce a prethrombotic state? Analysis of coagulation system activation and comparison to electrophysiologic study. J CardiovascElectrophysiol. 1998;9(11):1152–60.

    Article  CAS  Google Scholar 

  7. Ren JF, Marchlinski FE, Callans DJ. Left atrial thrombus associated with ablation for atrial fibrillation: identification with intracardiac echocardiography. J Am Coll Cardiol. 2004;43(10):1861–7.

    Article  PubMed  Google Scholar 

  8. Santangeli P, Di Biase L, Horton R, Burkhardt JD, Sanchez J, Al-Ahmad A, et al. Ablation of atrial fibrillation under therapeutic warfarin reduces periprocedural complications: evidence from a meta-analysis. Circ Arrhythm Electrophysiol. 2012;5(2):302–11.

    Article  CAS  PubMed  Google Scholar 

  9. Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomized trials. Lancet. 2014;383(9921):955–62.

    Article  CAS  PubMed  Google Scholar 

  10. Spinler SA, Shafir V. New oral anticoagulants for atrial fibrillation. Circulation. 2012;126(1):133–7.

    Article  PubMed  Google Scholar 

  11. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139–51.

    Article  CAS  PubMed  Google Scholar 

  12. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883–91.

    Article  CAS  PubMed  Google Scholar 

  13. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981–92.

    Article  CAS  PubMed  Google Scholar 

  14. Keating GM. Apixaban: a review of its use for reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Drugs. 2013;73(8):825–43.

    Article  CAS  PubMed  Google Scholar 

  15. Lu D, Liu Q, Wang K, Zhang QI, Shan QJ. Meta-analysis of efficacy and safety of apixaban in patients undergoing catheter ablation for atrial fibrillation. Pacing Clin Electrophysiol. 2016;39(1):54–9.

    Article  PubMed  Google Scholar 

  16. Kuwahara T, Abe M, Yamaki M, Fujieda H, Abe Y, Hashimoto K, et al. (2016). Apixaban versus Warfarin for the prevention of periprocedural cerebral Thromboembolism in atrial fibrillation ablation: multicenter prospective randomized study. J Cardiovasc Electrophysiol.

  17. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med. 2001;134(8):663–94.

    Article  CAS  PubMed  Google Scholar 

  19. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12.

    Article  CAS  PubMed  Google Scholar 

  20. Menzies D. Systematic reviews and meta-analyses. Int J Tuberc Lung Dis. 2011;15(5):582–93.

    Article  CAS  PubMed  Google Scholar 

  21. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. (2011). The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses [webpage on the Internet]. Ottawa, ON: Ottawa Hospital Research Institute; 2011. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.as.

  22. Higgins JPT, Green S. (editors). (2011). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org

  23. Bin Abdulhak AA, Kennedy KF, Gupta S, Giocondo M, Ramza B, Wimmer AP. Effect of pre procedural interrupted apixaban on heparin anticoagulation during catheter ablation for atrial fibrillation: a prospective observational study. J Interv Card Electrophysiol. 2015;44(2):91–6.

    Article  PubMed  Google Scholar 

  24. Di Biase L, Lakkireddy D, Trivedi C, Deneke T, Martinek M, Mohanty S, et al. Feasibility and safety of uninterrupted periprocedural apixaban administration in patients undergoing radiofrequency catheter ablation for atrial fibrillation: results from a multicenter study. Heart Rhythm. 2015;12(6):1162–8.

    Article  PubMed  Google Scholar 

  25. Kaess BM, Ammar S, Reents T, Dillier R, Lennerz C, Semmler V, et al. Comparison of safety of left atrial catheter ablation procedures for atrial arrhythmias under continuous anticoagulation with apixaban versus phenprocoumon. Am J Cardiol. 2015;115(1):47–51.

    Article  PubMed  Google Scholar 

  26. Nagao T, Inden Y, Yanagisawa S, Kato H, Ishikawa S, Okumura S, et al. Differences in activated clotting time among uninterrupted anticoagulants during the periprocedural period of atrial fibrillation ablation. Heart Rhythm. 2015;12(9):1972–8.

    Article  PubMed  Google Scholar 

  27. Rillig A, Lin T, Plesman J, Heeger CH, Lemes C, Metzner A, et al. Apixaban, rivaroxaban and dabigatran in patients undergoing atrial fibrillation ablation. J Cardiovasc Electrophysiol. 2016;27(2):147–53.

    Article  PubMed  Google Scholar 

  28. Kok LC, Mangrum JM, Haines DE, Mounsey JP. Cerebrovascular complication associated with pulmonary vein ablation. J Cardiovasc Electrophysiol. 2002;13(8):764–7.

    Article  PubMed  Google Scholar 

  29. Natale A, Raviele A, Arentz T, Calkins H, Chen SA, Haissaguerre M, et al. Venice Chart international consensus document on atrial fibrillation ablation. J Cardiovasc Electrophysiol. 2007;18(5):560–80.

    Article  PubMed  Google Scholar 

  30. Connolly SJ, Eikelboom J, O’Donnell M, Pogue J, Yusuf S. Challenges of establishing new antithrombotic therapies in atrial fibrillation. Circulation. 2007;116(4):449–55.

    Article  PubMed  Google Scholar 

  31. Mavrakanas T, Bounameaux H. The potential role of new oral anticoagulants in the prevention and treatment of thromboembolism. Pharmacol Ther. 2011;130(1):46–58.

    Article  CAS  PubMed  Google Scholar 

  32. Hohnloser SH, Camm AJ. Safety and efficacy of dabigatran etexilate during catheter ablation of atrial fibrillation: a meta-analysis of the literature. Europace. 2013;15(10):1407–11.

    Article  PubMed  Google Scholar 

  33. Garg J, Chaudhary R, Krishnamoorthy P, Shah N, Natale A, Bozorgnia B. Safety and efficacy of uninterrupted periprocedural rivaroxaban in patients undergoing atrial fibrillation catheter ablation: A metaanalysis of 1,362 patients. Int J Cardiol. 2016;203(15):906–8.

    Article  PubMed  Google Scholar 

  34. Ellis ER, Culler SD, Simon AW, Reynolds MR. Trends in utilization and complications of catheter ablation for atrial fibrillation in Medicare beneficiaries. Heart Rhythm. 2009;6(9):1267–73.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Shah RU, Freeman JV, Shilane D, Wang PJ, Go AS, Hlatky MA. Procedural complications, rehospitalizations, and repeat procedures after catheter ablation for atrial fibrillation. J Am Coll Cardiol. 2012;59(2):143–9.

    Article  PubMed  Google Scholar 

  36. Deshmukh A, Patel NJ, Pant S, Shah N, Chothani A, Mehta K, et al. In-hospital complications associated with catheter ablation of atrial fibrillation in the United States between 2000 and 2010: analysis of 93 801 procedures. Circulation. 2013;128(19):2104–12.

    Article  PubMed  Google Scholar 

  37. Siegal DM, Curnutte JT, Connolly SJ, Lu G, Conley PB, Wiens BL, et al. Andexanet alfa for the reversal of factor Xa inhibitor activity. N Engl J Med. 2015;373(25):2413–24.

    Article  CAS  PubMed  Google Scholar 

  38. Konduru SV, Cheema AA, Jones P, Li Y, Ramza B, Wimmer AP. Differences in intraprocedural ACTs with standardized heparin dosing during catheter ablation for atrial fibrillation in patients treated with dabigatran vs. patients on uninterrupted warfarin. J Interv Card Electrophysiol. 2012;35(3):277–84.

    Article  PubMed  Google Scholar 

  39. Winkle RA, Mead RH, Engel G, Kong MH, Patrawala RA. Atrial fibrillation ablation using open-irrigated tip radiofrequency: experience with intraprocedural activated clotting times ≤210 seconds. Heart Rhythm. 2014;11(6):963–8.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiology, S. Andrea Hospital, Corso Mario Abbiate 21, 13100, Vercelli, Italy

    Alessandro Blandino & Francesco Rametta

  2. Division of Cardiology, Mauriziano Umberto I Hospital, Turin, Italy

    Francesca Bianchi, Stefano Grossi & Maria Rosa Conte

  3. Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy

    Giuseppe Biondi-Zoccai

  4. Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy

    Giuseppe Biondi-Zoccai

  5. Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy

    Fiorenzo Gaita

Authors
  1. Alessandro Blandino
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Francesca Bianchi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Giuseppe Biondi-Zoccai
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Stefano Grossi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Maria Rosa Conte
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Francesco Rametta
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Fiorenzo Gaita
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alessandro Blandino.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Blandino, A., Bianchi, F., Biondi-Zoccai, G. et al. Apixaban for periprocedural anticoagulation during catheter ablation of atrial fibrillation: a systematic review and meta-analysis of 1691 patients. J Interv Card Electrophysiol 46, 225–236 (2016). https://doi.org/10.1007/s10840-016-0141-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-016-0141-6

Keywords

Search

Navigation