Author + information
- Received October 11, 2019
- Revision received November 22, 2019
- Accepted December 3, 2019
- Published online May 18, 2020.
- Aleksandr Voskoboinik, MBBS, PhDa,b,
- Eric Butcher, BAc,
- Amneet Sandhu, MDc,
- Duy T. Nguyen, MDc,
- Wendy Tzou, MDc,
- Domenico G. Della Rocca, MDd,
- Andrea Natale, MDd,
- Erica S. Zado, PA-Ce,
- Francis E. Marchlinski, MDe,
- Martin Aguilar, MDf,
- William Sauer, MDf,
- Usha B. Tedrow, MDf and
- Edward P. Gerstenfeld, MDa,∗ (, )@ed_gerst
- aDivision of Cardiology, University of California San Francisco, San Francisco, California
- bDivision of Cardiology, Alfred Hospital and Baker Heart Institute, Melbourne, Australia
- cDivision of Cardiology, University of Colorado, Denver, Colorado
- dTexas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas
- eDivision of Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- fCardiac Arrhythmia Service, Brigham and Women’s Hospital, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Edward P. Gerstenfeld, Division of Cardiology, University of California, 500 Parnassus Avenue, San Francisco, California 94143.
Objectives The goal of this study was to report a multicenter series of left-sided catheter ablations performed by using intravenous direct thrombin inhibitors (DTIs) as an alternative to heparin.
Background Amidst a looming worldwide shortage of heparin, there are insufficient data to guide nonheparin-based peri-procedural anticoagulation in patients undergoing catheter ablation.
Methods This study reviewed all catheter ablations at 6 institutions between 2006 and 2019 to assess the safety and efficacy of DTIs for left-sided radiofrequency catheter ablation of atrial fibrillation and ventricular tachycardia.
Results In total, 53 patients (age 63.0 ± 9.3 years, 68% male, CHA₂DS₂-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score 2.8 ± 1.6, left ventricular ejection fraction 46 ± 15%) underwent ablation with DTIs (75% bivalirudin, 25% argatroban) due to heparin contraindication(s) (72% heparin-induced thrombocytopenia, 21% heparin allergy, 4% protamine reaction, and 4% religious reasons). The patient’s usual oral anticoagulant was continued without interruption in 69%. Procedures were performed for atrial fibrillation (64%) or ventricular tachycardia/premature ventricular contractions (36%). Transseptal puncture was undertaken in 81%, and a contact force–sensing catheter was used in 70%. Vascular ultrasound was used in 71%, and femoral arterial access was gained in 36%. A bolus followed by infusion was used in all but 4 cases, and activated clotting time was monitored peri-procedurally in 72%, with 32% receiving additional boluses. Procedure duration was 216 ± 116 min, and ablation time was 51 ± 22 min. No major bleeding or embolic complications were observed. Four patients had minor self-limiting bleeding complications, including a small pericardial effusion (<1 cm), a small groin hematoma, and hematuria.
Conclusions In this multicenter series, intravenous DTIs were safely used as an alternative to heparin for left-sided catheter ablation.
- catheter ablation
- direct thrombin inhibitors
- heparin-induced thrombocytopenia
Dr. Voskoboinik is supported by the Heart Rhythm Society and the National Heart Foundation of Australia. Dr. Tzou has received speaker honoraria and consulting fees from Abbott and Biosense Webster; has received speaker honoraria and research funding from Boston Scientific; and has received speaker honoraria from Medtronic. Dr. Natale has served as a consultant/speaker for Biosense Webster, Medtronic, Biotronik, St. Jude/Abbott, and Baylis. Dr. Tedrow has received honorarium from Abbott and Biosense Webster; and has received consulting fees from Thermedical Inc. Dr. Gerstenfeld has received honoraria from Biosense-Webster, Boston Scientific, and Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Kenneth Ellenbogen, MD, served as Guest Editor for this paper.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received October 11, 2019.
- Revision received November 22, 2019.
- Accepted December 3, 2019.
- 2020 American College of Cardiology Foundation
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