Background

Catheter ablation of ventricular arrhythmias (VA) has emerged to an effective procedure for ventricular arrhythmias (VA) in patients with and without structural heart disease. The optimal periprocedural management with regards to prescription and maintenance of anti-thrombotic medical therapy is not yet defined. The current study sought to assess the frequency of periprocedural safety events in relation to the status of anti-thrombotic medication in a large cohort of patients undergoing VA ablation procedures.

Methods

This investigation was an observational monocenter study in a high-volume electrophysiology center. Procedures performed from 2002 until 2017 were analysed. All adverse periprocedural events which occurred intraprocedural or during the patients hospital stay for VA ablation were registered. Ablation procedures consisted of procedures for premature ventricular contraction (PVC) and sustained ventricular tachycardia (VT) including epicardial mapping and ablation procedures. Oral anticoagulation consisted of therapy with vitamin K antagonists (VKA) and direct oral anticoagulation (DOAC). Patients on VKA therapy underwent ablation with heparin bridging until 2012 and afterwards without therapy interruption aiming at INR levels of 2.0-2.5. In patients with direct oral anticoagulation (DOAC) medication was stopped 24 hours before the procedure. In patients on dual antiplatelet therapy (with or without concomitant OAC) the medication was continued throughout the treatment process.

Multivariable risk factor analysis for occurrence of major complications and intrahospital mortality was conducted.Therefore a logistic regression model was applied to relate covariates that were selected according to medical points of view to the incidence of complications and periprocedural death. All p-values were two-sided and a p-value <0.05 was considered significant.

A total of 1417 patients (804 patients with structural heart disease) undergoing 1792 ablation procedures for PVC and VT were analysed. Patients were without antithrombotic therapy or with a single antiplatelet drug in 1250 cases, with OAC in 445 cases, with DAPT in 125 cases and with triple therapy in 25 cases. Major complications occurred in 77/1792 procedures (4.4% of all procedures). Major bleeding events were the most common major complications including vascular access complications, cardiac tamponade and other major bleeding events occurring in 55/1792 cases (3.1%).

Major complications occurred in 38/1250 patients without antiplatelet therapy or single antiplatelet therapy (3.0%, 30 major bleeding events), 30/445 of patients with OAC (6.7%, 26 major bleeding events) and 9/125 cases of patients with DAPT (7.2%, 7 major bleeding events).

Logistic regression model revealed presence of OAC (p=0.05) and DAPT (p=0.05) as independent risk factors for the occurrence of complications and periprocedural death.

Conclusions

The presence of anti-thrombotic therapy was an independent risk factor for major complications and periprocedural death. The rate of major bleeding events was significantly higher in patients on OAC and/or DAPT as compared to patients without OAC or DAPT. Our results indicate that procedures in patients on temporary anti-thrombotic medication may be delayed to improve patients’ safety if patients are in a stable electrical clinical status. Further studies are warranted to improve periprocedural management in patients with anti-thrombotic medication.