Optimal strategies including use of newer anticoagulants for prevention of stroke and bleeding complications before, during, and after catheter ablation of atrial fibrillation and atrial flutter

Opinion statement: Anticoagulation is a key component of peri-procedural care for patients undergoing catheter ablation for atrial fibrillation (AF) and atrial flutter (AFL). The timing of discontinuation and re-initiation of anticoagulants in the peri-procedural time frame is an important consideration in trying to minimize the risk of stroke and procedure-related bleeding. Until recently, options for oral anticoagulation were limited to warfarin, which typically requires 4-5 days before a therapeutic International Normalized Ratio (INR) is achieved. Therefore, patients deemed to have a high risk of peri-procedural stroke had to either have their procedure performed with a therapeutic INR, or with cessation of warfarin and the adjunctive use of bridging heparinoids. Recently, however, three novel oral anticoagulant agents, each with a rapid onset of action, have been approved by the FDA for use in thromboembolism prophylaxis in patients with AF and AFL. These new drugs (dabigatran, rivaroxaban, and apixaban) broaden the menu of options with regard to peri-procedural anticoagulation strategies that can be employed for ablation of AF and AFL.