Anticoagulation prior to ablation

[Aqua_1]

I have seen two EPs so far and both agree that at this point in time i do not need to take anticoagulants, however the first EP i saw mentioned to me that i would be required to take an anticoagulant 4 weeks prior to ablation and 3 months post procedure. The 2nd EP told me that i would not require pre procedure however post procedure i would need to take for 3 months. Any thoughts why one insists that i start on anti coagulants prior to procedure whilst the other doesn't think they are necessary? Thanks in advance for your replies.

[KMRobbo]

No idea as to the varying requirement. My ep had me on 25 days a/c dabigatran (pradaxa) pre ablation and approx 3 months post ablation. So similar to one of your EPs.

[KMRobbo]

I should say I am 58 with chads2vasc of zero

[Aqua_1 in reply to KMRobbo]

Thanks KMRobbo I am 51 with a chads2vasc of zero as well.

[CDreamer]

I was asked to be on DOAC for 2 weeks prior to ablation. And 3months + after. I was approaching 65 and female so CHADS of 2 = low-moderate risk and I was having almost daily AF episodes.

I would imagine the ‘prior to’ requirement would be to ensure there weren’t any clots about to form - they will do a TOE anyway but as a precaution - I was very happy to take Dabigatran. Wouldn’t contemplate Wafarin because of the variability and the uncertaintity of being within INR tolerances.

Tremendous variation between recommendations between countries and various specialists - have you looked up best practice guidelines? I think I would go with that recommendation.

[Aqua_1 in reply to CDreamer]

Thanks CDreamer, I haven't been able to find any guidelines online however reading everyone's responses here it would be in my very best interests to follow the advice of the EP who insists that I take the anti coags pre procedure.

[Hidden]

I would want to be on the med going in for the procedure as there are variables that I feel would leave me vulnerable. You will be anticoagulated during the ablation but as this intraoperative med is usually reversed before you get off the operating table you will not be protected until your first anticoagulant pill. They reverse your dose given during surgery so you don't bleed afterward. After your procedure will someone be standing by to be sure you receive your first dose right away? or might you have a nurse or a pharmacist who is busy and late getting that first dose to you? Maybe you'll be nauseated and not able to swallow a pill. Meanwhile new tissue is already beginning to form over the ablated areas which could affect clot formation after surgery. I would rather eliminate even the smallest window of chance for clot formation. I think the doctor who says the meds are not necessary pre-op is being a little cavalier. Better safe than sorry. Also, if your pre-op TOE shows evidence of clot formation your ablation will be cancelled until the situation is remedied and you get to go back to square one and start the whole ablation process over. Take the meds pre-op and cover yourself 100%. By the way I'm in the US, have had an ablation and the standard of care is 4 weeks of anticoagulants prior to the ablation. My Chad score was 2 but even if it had been zero I would have insisted on the pre-op meds. Just my opinion but something to consider:. The doctor will not be the one having the stroke. He will be home having dinner with his family. A good question to ask might be "Doctor, what would you advise if I were your mother, sister, father....?" You get the picture. Take care. irina

[Aqua_1 in reply to Hidden]

Good advice irina. The more I think about it the more I am thinking to go with the EP who has advised that anti coags pre procedure are mandatory.

[BobD Volunteer]

The "not before is unusual" but if the EP plans on doing a TOE to check for any possible clots before starting the procedure this may explain it.

[Aqua_1 in reply to BobD]

Thanks Bob both EPs plan on doing TOE. The EP who prefers RF has said that I must take anti coags pre procedure and the one who prefers CRYO said anti coags pre procedure are not required .

[IanMK]

Perhaps the first EP had in mind an antigoagulant that takes a while to build up effectiveness and the second EP had in mind an anticoagulant that is effective immediately. This is a question I would ask your EPs. I’m sure they have their reasons.

[Aqua_1 in reply to IanMK]

Thanks Ian, from reading these replies it seems the norm is to take an anticoagulant pre procedure. This is the same EP whose preference is RF over CRYO. Not sure if that makes a difference but I will be sure to ask him.

[pottypete1]

This does surprise me as with all my many ablations I had to be anticoagulated, in addition I either had to have a TOE scan a few days before or in 3 cases they did a TOE on the table prior to starting work on the actual ablation.

As I was on Warfarin I was told that I had to have an INR between 2 & 3. I had to have 4 weekly blood tests prior to each ablation. They also checked on the day and I was told that if I was outside that range the ablation would be postponed.

Pete

[MarkS]

Recent research has shown that ablations cause a lot of micro-emboli to be produced during the procedure itself. These can cause "Silent Cerebral Ischaemic Lesions" or SCILs. These SCILs can result in permanent damage and there is also concern that they lead to long term cognitive damage.

Using OAC before and during the ablation (and not bridging with Heparin) results in far fewer of these being produced. A TOE beforehand is not of course going to spot these.

So I think your first EP is right.

[Aqua_1 in reply to MarkS]

Thanks MarkS, that's good to know. The first EP is also the one that performs RF ablation and I am feeling more comfortable with his advice.

[BobD Volunteer in reply to MarkS]

Thank you for that Mark. I have for a long time had that theory in my mind to explain what people often refer to as brain fog but was not aware that it had been proven.

[Hidden in reply to BobD]

Hi Bob. Along these lines: When we first started doing open heart surgery in the 60's at the hospital I worked in it was noted, though not well-documented at the time-that almost all of the patients had memory problems for various lengths of time immediately after surgery if they had been placed on the heart lung machine. The patients were in the Intensive Care Unit which was next to the O.R. Because the heart surgery program was new it was common to walk over and see how they were doing. Their memory problems usually resolved in a few days but it was evident that some type of brain fog was taking place.

[Hidden in reply to MarkS]

This makes sense. Whatever way the ablation is performed there will still be internal injured tissue that is more prone to the micro clots than tissue that has been left untouched. Any surgery is an insult to tissue and while healing takes place we should be given every safeguard to prevent complications. Surgery is not an area where a cavalier attitude from anyone serves us well. When we agree to surgery we turn our bodies over to someone else's care 100% and if a surgeon indicates he takes this lightly in any way move on. No surgery should be taken lightly. Just my opinion. Good luck. Go with the one who is showing the most concern for your overall wellbeing. irina

[doodle68]

Hi Aqua I note in a previous post you say....

[I have seen two EP's with a view to getting an ablation. One has advised that he will use the cryoablation technique whilst the other has mentioned radiofrequency. Whilst i know whats involved in both techniques i am not sure which one is better/safer than the other? FYI i have paroxysmal AF and diagnosed earlier this year.]

Maybe the method of ablation is influencing the EP's decision with regard to anticoagulation. I would ask both of them about the reason for their choice of anticoagulation and why they differ.

[Maura5]

I am female 56 years old, chadsvasc =1

I had my ablation 1 week ago and was not prescribed any anticoagulants prior to the procedure. I have been prescribed Rivaroxaban for six weeks post ablation. I had a TOE before the procedure to check for clots.

[Hidden in reply to Maura5]

My Electrophysiologist would say the pre-op TOE is only a 'snapshot in time." So it makes sense to have it immediately before your ablation. Doing a TOE 3 days prior gives you 3 days to develop a clotting problem that may not be picked up. I had my TOE (TEE here in the US) on the operating table a few minutes before the Pacemaker and Ablation began. So no time for clotting probs to arise before ablation.

[Aqua_1 in reply to Hidden]

Thanks irina, the EP who prefers RF ablation over CRYO and recommends anticoagulants prior to procedure also does the TOE on the same day as the ablation procedure. A few weeks prior to the procedure i would be required to have a Cardiac CT scan as well. I already had one earlier this year however he told me that this particular ct scan is different. The other EP mentioned he would either refer to the ct scan i already had or he might get me to have another one. Not sure what CT scan either EP is referring to? I guess i have more questions to ask.

[Hidden in reply to Aqua_1]

I like him even more. He is also showing respect for you as a person (not just a procedure) by explaining what he wants to do and why. This approach encourages patients to voice their questions and concerns instead of offering you a quick paternalistic rundown of his approach.

[Aqua_1 in reply to Hidden]

Truth is he has shown alot of respect towards me and also encourages me to ask questions.

[Maura5 in reply to Hidden]

Yes, I also had my TOE on the operating table 👍

[Hidden in reply to Maura5]

Hope you are doing well , Maura. It appears your doctor was also caring. When we have to come to the hospital for separate individual procedures when they can easily be done together during one visit I believe the doctor is not mindful of the stress, time, and inconveniece that this approach causes patients. It's like your car mechanic saying. "I'll fix your brakes today; come back in 2 days and I'll rotate your tires, and next Monday I'll change the oil. "To me this is ridiculous and disrespectful of our time and ultimately of us as people. I suspect doctors who use this piecemeal approach are doing it because the choppy timeframe may be more convenient to their schedules . There is another facet of interest. It concerns the financial aspect of operating room income. Operating rooms charge by time used with the first part of a procedure earning more income because set up time, supplies, etc is also included. So if a room has 5 shorter ablations scheduled on a certain day it will generate more income than 3 longer ones that include ancillary procedures.. If ancillary procedures like a TOE can be done at another time and in another dept everyone wins financially. I spent years working in operating rooms and not much of the infrastructure escaped me. Take care. irina

[Aqua_1]

Thanks Doodle68. Silly me I should have provided further details to all you wonderful people who have replied. The EP using the CRYO method said NO coags pre procedure and the one using RF is saying that coags are required pre procedure and not negotiable. He will not perform the procedure if I do not follow those instructions.

[Hidden in reply to Aqua_1]

The one recommending the RF and insisting on taking the pre meds sounds like he would be my choice. irina

[KMRobbo]

Just to confuse things further, my first ablation was cryo but I still had to have 25 days on Dabigatran pre ablation!

[Aqua_1 in reply to KMRobbo]

Confusing indeed! The instructions from the EP who does CRYO are 'Dabigatran, Apxaban MUST be stopped 48 hours prior to the procedure', so I understand that this applies to patients that are taking anticoagulants anyway and those like myself who do not take them at all would not need to start them till after the procedure.

[BobD Volunteer in reply to Aqua_1]

Most recently I have been told many EPs do NOT stop anticoagulation prior to ablation. As MarkS has stated above this avoids or reduces the possibility of micro embolii forming.

[Hidden in reply to BobD]

Interesting Update. It would make sense that 100% continuous coverage up to the ablation would lower the risk of micro emboli even more. My guess is they have probably reduced the amount of anticoagulant needed during the ablation taking into account what is still remaining in the body. I do know a close check is kept on INR's/ PT's during the procedure. Sounds like a good change in the anticoagulant balancing act. Thanks for the info, Bob. irina

[Hidden in reply to Aqua_1]

The reason for this most likely is because taking into consideration the 1/2 life of the pre meds, the doctor is going to use anticoagulants during the ablation to prevent clots during your procedure. By clearing your system briefly immediately before surgery he will start his anticoaguation with a 'clean slate' so to speak. When he is finished he will give you medication to reverse the anticoagulants he used before you leave the operating room and you will again have a clean slate for your post operative anticoagulants he prescribes. This process requires delicate balancing pre-operatively, during your procedure, and immediately post operatively. The RF doc sounds like he wants the best possible outcome for you and doesn't want to leave anything to chance. As the saying goes: 'Sounds like a keeper.' irina

[Aqua_1 in reply to Hidden]

I have to agree with you irina.