Ablation of Atrial Fibrillation Without Left Atrial Appendage Imaging in Patients Treated With Direct Oral Anticoagulants

BACKGROUND-Many centers continue to routinely perform trans-esophageal echocardiograms (TEE) prior to atrial fibrillation (AF) ablation procedures in patients treated with direct oral anticoagulants (DOAC). One study suggested that the procedures could be done without TEE but employed intracardiac echo (ICE) imaging of the appendage from the right ventricular outflow. This study aimed to assess the safety of ablation for AF without TEE screening or ICE imaging of the appendage in DOAC compliant patients. METHODS-All patients undergoing AF ablation at the Cleveland Clinic (2011-2018) were enrolled in a prospectively maintained data registry. All consecutive patients presenting with AF or atrial flutter (AFL) on DOAC were included. Peri-procedural thromboembolic complications were assessed. RESULTS-A total of 900 patients were included. Their median CHA2DS2-VASc score was 2 (interquartile range 1-3). All were on DOACs (333 Rivaroxaban, 285 Dabigatran, 281 Apixaban, and 1 Edoxaban). Thrombo-embolic complications occurred in 4 patients (0.3%)2 ischemic strokes; 1 transient ischemic attack without residual deficit and 1 splenic infarct; all with no further complications. Bleeding complications occurred in 5 patients (0.4%)2 pericardial effusions (1 intra-operative, 1 after 30 days, both drained), 3 groin hematomas (1 of them due to needing heparin for venous thrombosis, none required interventions). No patients required emergent surgeries. CONCLUSIONS-In DOAC compliant patients who present for ablation in AF/AFL, the procedures could be performed without TEE screening or ICE imaging of the appendage; with low risk of complications.