• Luigi Di Biase, David F Briceno, Chintan Trivedi, Sanghamitra Mohanty, Carola Gianni, J David Burkhardt, Prasant Mohanty, Rong Bai, Sampath Gunda, Rodney Horton, Shane Bailey, Javier E Sanchez, Amin Al-Ahmad, Patrick Hranitzky, G Joseph Gallinghouse, Yaruva Madhu Reddy, Jason Zagrodzky, Richard Hongo, Salwa Beheiry, Dhanunjaya Lakkireddy, and Andrea Natale.
• Texas Cardiac Arrhythmia Institute at St David Medical Center, Austin, Texas; Albert Einstein College of Medicine at Montefiore Hospital, New York, New York; University of Texas, Department of Biomedical Engineering, Austin, Texas; Department of Cardiology, University of Foggia, Foggia, Italy.
• Heart Rhythm. 2016 Jun 1; 13 (6): 1197-202.

BackgroundTransesophageal echocardiography (TEE) is recommended in patients undergoing atrial fibrillation (AF) ablation, but use of this strategy is variable.ObjectiveTo evaluate whether TEE is necessary before AF ablation in patients treated with novel oral anticoagulants (NOACs).MethodsWe performed a prospective multicenter registry of AF patients undergoing radiofrequency catheter ablation on uninterrupted NOACs (apixaban and rivaroxaban). All patients were on NOACs for at least 4 weeks before ablation. Heparin bolus was administered to all patients before transseptal catheterization to maintain a target activated clotting time above 300 seconds. A subset of 86 patients underwent brain diffuse magnetic resonance imaging (dMRI) to detect silent cerebral ischemia (SCI).ResultsA total of 970 patients (514 [53%] apixaban patients and 456 [47%] rivaroxaban patients) were enrolled for this study. The mean age was 69.5 ± 9.0 years, with 824 patients (85%) having nonparoxysmal AF, and 636 patients (65.6%) were male. The average CHA2DS2-VASc score was 3.01 ± 1.3 and CHADS2 score was ≥2 in 609 patients (62.8%). Intracardiac echocardiogram ruled out left atrial appendage thrombus in all patients whose left atrial appendage was visualized (692, 71%), and detected "smoke" in 407 patients (42%). SCI at postprocedure dMRI was detected in 2.3% (2/86). One thromboembolic event (transient ischemic attack) (0.10%) with positive dMRI occurred in a patient on uninterrupted rivaroxaban with longstanding persistent AF.ConclusionOur study illustrates that performing AF ablation while on uninterrupted apixaban and rivaroxaban without TEE is feasible and safe. This finding has important clinical and economic relevance.Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

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