Catheter ablation for atrial fibrillation on uninterrupted direct oral anticoagulants: A safe approach.

BACKGROUND: Current consensus guidelines suggest direct oral anticoagulants (DOACs) are interrupted periprocedurally for catheter ablation (CA) of atrial fibrillation (AF). However, this may predispose patients to thromboembolic complications. This study investigates the safety of CA for AF on uninterrupted DOACs compared to uninterrupted warfarin. METHODS: This was a single-center, retrospective study of consecutive patients undergoing CA for AF. All patients were heparinized prior to transseptal puncture with a target-activated clotting time (ACT) of 300-350 seconds. Patients who had procedures performed on continuous DOAC were compared to those on continuous warfarin. Clinical, procedural data, and complications occurring up to 3 months were analyzed from a prospective registry with additional review of electronic health records. RESULTS: A total of 1,884 procedures were performed over 28 months: 761 (609 patients) on uninterrupted warfarin and 1,123 (900 patients) on uninterrupted DOAC (rivaroxaban 64%, apixaban 32%, and dabigatran 4%). There was no difference in the composite endpoint of death, thromboembolism, or major bleeding complication (2.2% vs 1.4%, P = 0.20). There was no difference in the complications comprising this, including tamponade, hematoma, pseudoaneurysm, and transfusion (P-values 0.28, 0.13, 0.45, and 0.36). There were no strokes, transient ischemic attacks, or other thromboembolic complications. There was no difference between groups in the proportion of tamponades requiring reversal of oral anticoagulation, the volume of blood lost, the proportion transfused, or the proportion drained percutaneously (P-values 0.50, 0.51, 0.36, and 0.38). CONCLUSION: Catheter ablation for AF can be performed safely and effectively in patients anticoagulated with DOACs and heparinized with a therapeutic ACT. There is no increased risk of periprocedural bleeding when compared to uninterrupted warfarin.

Successful use of blood pleurodesis to resolve an iatrogenic persistent pneumothorax in a patient with pulmonary tuberculosis.

A Somali patient with previous tuberculosis presented clinically unwell with features consistent with a right-sided pleural effusion. Subsequent investigations confirmed a community-acquired pneumonia and relapse of pulmonary tuberculosis, with a drug resistant strain isolated. The patient developed a large left-sided iatrogenic pneumothorax, which recurred and failed to resolve despite the successful insertion of both Seldinger and surgical chest drains, and the patient remained clinically unstable on the intensive care unit. A blood pleurodesis was successfully used to provide resolution of this patient's previously persistent pneumothorax, which has resulted in stabilisation of the patient and no further pneumothoraces have occurred subsequently. The authors therefore highlight the use of a blood pleurodesis as a little used technique that may provide a valuable tool to other clinicians in similar cases.