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Rivaroxaban for Atrial Fibrillation Ablation
Study Questions:
How do uninterrupted rivaroxaban and warfarin compare as prophylactic agents against atrial fibrillation (AF) catheter ablation-induced asymptomatic cerebral infarctions?
Methods:
Patients with nonvalvular AF undergoing radiofrequency catheter ablation were randomly assigned to uninterrupted rivaroxaban or warfarin pre-procedure. Ablation was performed after ≥1 month of adequate anticoagulation. Cerebral magnetic resonance imaging (MRI) was performed before and after catheter ablation to assess for asymptomatic cerebral infarcts.
Results:
Among 127 patients completing the study protocol, the rates of catheter ablation-induced asymptomatic cerebral infarcts were similar between patients treated with rivaroxaban and warfarin (15.6% vs. 15.9%, respectively, p = 1.0). No thromboembolic events developed during the study period. There were no differences in major bleeding (3.1% vs. 1.6%, p = 1.0) or clinically relevant nonmajor bleeding (18.8% vs. 19.0%, p = 1.0) between the rivaroxaban and warfarin study arms. Pre-existing deep and subcortical white matter hyperintensity (adjusted odds ratio [aOR], 5.323; 95% confidence interval [CI], 1.804-15.704) and the frequency of cardioversions (aOR, 1.250; 95% CI, 1.043-1.499) were associated with the development of asymptomatic cerebral infarcts following catheter ablation.
Conclusions:
The authors concluded that there were no notable differences between uninterrupted rivaroxaban and warfarin therapies in the prevention of AF catheter ablation-induced asymptomatic cerebral infarcts.
Perspective:
This randomized study confirms the findings of prior work that uninterrupted direct oral anticoagulant therapy is safe and effective for patients with AF undergoing catheter ablation. Interestingly, this study compared before and after MRI to detect new asymptomatic cerebral infarct lesions and identify risk factors for developing these lesions. Prior neurologic changes and increased frequency of cardioversions were predictors of developing asymptomatic cerebral infarcts. Clinicians can feel confident about the use of uninterrupted rivaroxaban therapy for AF patients undergoing catheter ablation, but they may want to consider how frequently they perform cardioversion before attempting catheter ablation.
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Cerebral Infarction, Electric Countershock, Hemorrhage, Magnetic Resonance Imaging, Risk Factors, Thromboembolism, Vascular Diseases, Warfarin
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