Should catheter atrial fibrillation ablation be considered as a ‘high bleeding risk’ intervention?

We read with interest the last EHRA practical guide on the use of new oral anticoagulants (NOAC) in patients with non-valvular atrial fibrillation (AF) reported by Heidbuchel et al.,¹ and the problematic issue of NOAC during catheter AF ablation (CAFA). Several studies have confirmed the reduction of both bleeding and thromboembolic (TE) complications when performing CAFA during uninterrupted vitamin K antagonist therapy in comparison with a bridging strategy. Recent non-randomized studies with NOAC continued during CAFA showed similar safety profiles while still considering TE and bleeding events.²

In the absence of a specific classification including CAFA procedures, the present guideline concerning the NOAC strategy was based on the exact definition of the bleeding risk associated which CAFA, which can be ambiguous.

Careful reading of the text appears confusing in our opinion. In the text, the authors suggest NOAC interruption 48 h before a procedure that carries a ‘risk for major bleeding’ (p. 640), whereas in the corresponding Table 10, CAFA is classified within the group of ‘high bleeding risk’ interventions.¹ The table itself refers to a study reported in 2003 by Torn M et al.³ in which CAFA was completely absent from that classification. Should we consider CAFA as a procedure with ‘frequent’ bleeding complications?

There is a dissociation between these two concepts. On the one hand, the ‘risk of major bleeding’—this complication can be either frequent or exceptional—is defined by the gravity and/or consequence of per- or post-procedural bleeding. On the other hand, ‘high bleeding risk’ procedures refer to the rate of bleeding complications—the consequence of which going from mild to fatal. This concerns both the rate of bleeding complications, and their severity. Low bleeding risk procedures designate procedures with clinical bleeding rates of 1.5% or less in the classification from the American Society for Gastrointestinal Endoscopy.⁴ The worldwide survey on CAFA from Cappato et al. reports total bleeding rate events of 2.8% when adding tamponade, hemothorax, and groin complications. Then, according to the above-mentioned classification, CAFA can be defined as a procedure associated with a bleeding risk which is not low. But then, does this imply that it is a ‘high bleeding risk’ procedure?

In fact, CAFA is a procedure associated with major bleeding risk, because it can be complicated with transfusions, permanent disability (e.g. bleeding-induced stroke or myocardial infarction), and even death. Procedures that may result in intra-thoracic or pericardial bleeding are classified as major.⁵

The other confusion concerns the distinction—even though this may appear elementary—in the same table, between single-(associated with low bleeding risk) and double-transseptal puncture procedures. No reference is provided to support this proposal.

To conclude, in the absence of specific validated bleeding risk classification, CAFA can be defined as a major bleed risk procedure, and is not a low bleeding risk procedure.

Despite these remarks, we would like to sincerely thank Heidbuchel and his collaborators for this courageous practical guide which offers elements of answers in our daily practice.

Conflict of interest: none declared.

References