title: Epicardial catheter ablation for ventricular tachycardia on uninterrupted warfarin: A safe approach for those with a strong indication for peri-procedural anticoagulation?
abstract: BACKGROUND
  Current guidelines for epicardial catheter ablation for ventricular tachycardia (VT) advocate that epicardial access is avoided in anticoagulated patients and should be performed prior to heparinisation. Recent studies have shown that epicardial access may be safe in heparinised patients. However, no data exist for patients on oral anticoagulants. We investigated the safety of obtaining epicardial access on uninterrupted warfarin.
  
  
  METHODS
  A prospective registry of patients undergoing epicardial VT ablation over two years was analysed. Consecutive patients in whom epicardial access was attempted were included. All patients were heparinised prior to epicardial access with a target activated clotting time (ACT) of 300-350s. Patients who had procedures performed on uninterrupted warfarin (in addition to heparin) were compared to those not taking an oral anticoagulant.
  
  
  RESULTS
  46 patients were included of which 13 were taking warfarin. There was no significant difference in clinical and procedural characteristics (except INR and AF) between the two groups. Epicardial access was achieved in all patients. There were no deaths and no patients required surgery. A higher proportion of patients in the warfarin group had a drop in haemoglobin of >2g/dL compared to the no-warfarin group (38.5% versus 27.3%, p=0.74) and delayed pericardial drain removal (7.8% versus 3.03%, p=0.47). There was no difference in overall procedural complication rate. No patients required warfarin reversal or blood transfusion.
  
  
  CONCLUSIONS
  Epicardial access can be achieved safely and effectively in patients' anticoagulated with warfarin and heparinised with therapeutic ACT. This may be an attractive option for patients with a high stroke risk.
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom. Electronic address: sawhneyvin@googlemail.com.
authors.forename: V
authors.initials: V
authors.lastname: Sawhney
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom.
authors.forename: A
authors.initials: A
authors.lastname: Breitenstein
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom.
authors.forename: W
authors.initials: W
authors.lastname: Ullah
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom.
authors.forename: M
authors.initials: M
authors.lastname: Finlay
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom.
authors.forename: S
authors.initials: S
authors.lastname: Sporton
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom.
authors.forename: M J
authors.initials: MJ
authors.lastname: Earley
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom.
authors.forename: A W
authors.initials: AW
authors.lastname: Chow
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom.
authors.forename: M
authors.initials: M
authors.lastname: Dhinoja
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom.
authors.forename: P
authors.initials: P
authors.lastname: Lambiase
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom.
authors.forename: R J
authors.initials: RJ
authors.lastname: Schilling
authors.affiliation: Cardiology Department, St Bartholomew's Hospital, London, United Kingdom. Electronic address: rossjhunter@gmail.com.
authors.forename: R J
authors.initials: RJ
authors.lastname: Hunter
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods; D005260:Female; D006493:Heparin / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D010496:Pericardium / Q000601:surgery*; D019990:Perioperative Care / Q000379:methods / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000517:prevention & control*; D012042:Registries / Q000706:statistics & numerical data; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D017180:Tachycardia, Ventricular / Q000175:diagnosis / Q000188:drug therapy / Q000601:surgery; D006113:United Kingdom; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D000925:Anticoagulants; D014859:Warfarin; D006493:Heparin
keywords: Epicardial access; Heparin; Uninterrupted warfarin; VT ablation