title: Is transesophageal echocardiogram mandatory in patients undergoing ablation of atrial fibrillation with uninterrupted novel oral anticoagulants? Results from a prospective multicenter registry.
abstract: Transesophageal echocardiography (TEE) is recommended in patients undergoing atrial fibrillation (AF) ablation, but use of this strategy is variable.
  
  
  
  To evaluate whether TEE is necessary before AF ablation in patients treated with novel oral anticoagulants (NOACs).
  
  
  
  We performed a prospective multicenter registry of AF patients undergoing radiofrequency catheter ablation on uninterrupted NOACs (apixaban and rivaroxaban). All patients were on NOACs for at least 4 weeks before ablation. Heparin bolus was administered to all patients before transseptal catheterization to maintain a target activated clotting time above 300 seconds. A subset of 86 patients underwent brain diffuse magnetic resonance imaging (dMRI) to detect silent cerebral ischemia (SCI).
  
  
  
  A total of 970 patients (514 [53%] apixaban patients and 456 [47%] rivaroxaban patients) were enrolled for this study. The mean age was 69.5 ± 9.0 years, with 824 patients (85%) having nonparoxysmal AF, and 636 patients (65.6%) were male. The average CHA2DS2-VASc score was 3.01 ± 1.3 and CHADS2 score was ≥2 in 609 patients (62.8%). Intracardiac echocardiogram ruled out left atrial appendage thrombus in all patients whose left atrial appendage was visualized (692, 71%), and detected "smoke" in 407 patients (42%). SCI at postprocedure dMRI was detected in 2.3% (2/86). One thromboembolic event (transient ischemic attack) (0.10%) with positive dMRI occurred in a patient on uninterrupted rivaroxaban with longstanding persistent AF.
  
  
  
  Our study illustrates that performing AF ablation while on uninterrupted apixaban and rivaroxaban without TEE is feasible and safe. This finding has important clinical and economic relevance.
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas; Albert Einstein College of Medicine at Montefiore Hospital, New York, New York; University of Texas, Department of Biomedical Engineering, Austin, Texas; Department of Cardiology, University of Foggia, Foggia, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Di Biase
authors.affiliation: Albert Einstein College of Medicine at Montefiore Hospital, New York, New York.
authors.forename: David F
authors.initials: DF
authors.lastname: Briceno
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Chintan
authors.initials: C
authors.lastname: Trivedi
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Sanghamitra
authors.initials: S
authors.lastname: Mohanty
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Carola
authors.initials: C
authors.lastname: Gianni
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Prasant
authors.initials: P
authors.lastname: Mohanty
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Rong
authors.initials: R
authors.lastname: Bai
authors.affiliation: University of Kansas, Kansas City, Kansas.
authors.forename: Sampath
authors.initials: S
authors.lastname: Gunda
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Rodney
authors.initials: R
authors.lastname: Horton
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Shane
authors.initials: S
authors.lastname: Bailey
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Javier E
authors.initials: JE
authors.lastname: Sanchez
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Amin
authors.initials: A
authors.lastname: Al-Ahmad
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Patrick
authors.initials: P
authors.lastname: Hranitzky
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: G Joseph
authors.initials: GJ
authors.lastname: Gallinghouse
authors.affiliation: University of Kansas, Kansas City, Kansas.
authors.forename: Yaruva Madhu
authors.initials: YM
authors.lastname: Reddy
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas.
authors.forename: Jason
authors.initials: J
authors.lastname: Zagrodzky
authors.affiliation: California Pacific Medical Center, San Francisco, California.
authors.forename: Richard
authors.initials: R
authors.lastname: Hongo
authors.affiliation: California Pacific Medical Center, San Francisco, California.
authors.forename: Salwa
authors.initials: S
authors.lastname: Beheiry
authors.affiliation: University of Kansas, Kansas City, Kansas.
authors.forename: Dhanunjaya
authors.initials: D
authors.lastname: Lakkireddy
authors.affiliation: Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas; University of Texas, Department of Biomedical Engineering, Austin, Texas; California Pacific Medical Center, San Francisco, California; Stanford University, Palo Alto, California; Case Western Reserve University, Cleveland, Ohio; Scripps Clinic, San Diego, California,; Dell Medical School, Austin, Texas. Electronic address: dr.natale@gmail.com.
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D000368:Aged; D020517:Atrial Appendage / Q000000981:diagnostic imaging*; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology / Q000601:surgery*; D001777:Blood Coagulation / Q000187:drug effects; D002545:Brain Ischemia / Q000209:etiology / Q000517:prevention & control; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods; D017548:Echocardiography, Transesophageal / Q000379:methods*; D065427:Factor Xa Inhibitors / Q000627:therapeutic use; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D061214:Patient Safety; D011300:Preoperative Care / Q000379:methods; D011720:Pyrazoles / Q000627:therapeutic use*; D011728:Pyridones / Q000627:therapeutic use*; D012042:Registries / Q000706:statistics & numerical data; D000069552:Rivaroxaban / Q000627:therapeutic use*; D013927:Thrombosis / Q000175:diagnosis / Q000209:etiology; D014481:United States / Q000453:epidemiology
chemical_list: D065427:Factor Xa Inhibitors; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D000069552:Rivaroxaban
keywords: Ablation; Atrial fibrillation; NOAC; Transesophageal echocardiogram; Uninterrupted anticoagulation