The unfinished issue of ischaemic stroke and embolic events during ablation for atrial fibrillation: the authors' reply Free

We thank Dr. Providencia et al.¹ for the concern and comments on our article.² We agree with them that discontinuation of warfarin before catheter ablation for atrial fibrillation (AF) is likely associated with increased risk of periprocedural thrombo-embolic events. We cannot comment on the effects of different periprocedural anticoagulation strategy used in our cohort on thrombo-embolic events during AF ablation because of only a small minority of patients who were anti-coagulated with uninterrupted warfarin. Although several reports indicate that AF ablation can be performed safely with fewer stroke and bleeding complications when oral warfarin is continued in the periprocedural period,^3,4 it may be difficult to determine in some cases with high risk of major bleeding complications and over anticoagulation (such as the case 8 with complicated atrial tachyarrhythmia and long procedure duration) whether AF ablation without interruption of oral anticoagulation is an appropriate alternative.

In our study, previous ischaemic stroke, mechanical valve replacement, and CHA₂DS₂-VASc score ≥3 are identified as independent clinical predictors of cerebrovascular complications related to AF ablation. These results are not reproduced by Dr Providencia et al. from their data. The possible explanations for the fact include: (i) the CHA₂DS₂-VASc score has been proved to be better than CHADS₂ score for stroke risk stratification in Chinese patients;⁵ (ii) despite effective control and prevention for acute rheumatic fever, there remains a large number of patients with chronic rheumatic heart disease in China and thus patients with a previous history of mechanical valve replacement are commonly enrolled in our study, whereas most research is carried out in high-income countries where rheumatic heart disease is becoming rare.

Conflict of interest: none declared.

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