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Safety and efficacy outcomes of protamine administration for heparin reversal following cryoballoon-based pulmonary vein isolation

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Abstract

Purpose

Anticoagulation with heparin is required during catheter ablation of atrial fibrillation (AF) to reduce systemic thromboembolism. In this study, we aim to compare safety and efficacy outcomes between patients who receive protamine administration for reversal of heparin and those who do not, following cryoballoon-based pulmonary vein isolation (PVI) for AF.

Methods

Patients with symptomatic paroxysmal or persistent AF despite ≥1 antiarrhythmic drug(s) were scheduled for PVI per the recent consensus recommendations. Some patients were administered protamine at the end of the procedure depending on the operator’s choice.

Results

Among 380 patients [48.2 % male, 56 (20–86) years] that were enrolled, 188 patients received protamine at the end of the procedure. Baseline characteristics did not differ between groups (p > 0.05). Mean protamine dose was 39.1 ± 6.4 mg. Only 1 patient developed rash following protamine infusion. Hospital stay was significantly shorter in patients who were administered protamine (1 [1–5] vs. 2 [1–7] days, p < 0.001). Hematoma/pseudoaneurysm or femoral AV fistula requiring surgical or interventional repair in the femoral access site occurred in 2 (1.1 %) patients who received protamine and 12 (6.3 %) patients who did not (p = 0.011). Deep vein thrombosis was seen in 1 patient in whom protamine was not administered (p = 0.499).

Conclusion

To the best of our knowledge, this is one of the largest series showing that protamine administration for heparin reversal in patients undergoing cryoballoon-based PVI allows quicker sheath removal and minimizes the risk of potential vascular complications without causing an increase in thrombotic events.

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References

  1. January, C. T., Wann, L. S., Alpert, J. S., Calkins, H., Cigarroa, J. E., Cleveland, J. C., Jr., et al. (2014). 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation, 130(23), 2071–2104.

    Article  PubMed  Google Scholar 

  2. Hagens, V. E., Ranchor, A. V., Van Sonderen, E., Bosker, H. A., Kamp, O., Tijssen, J. G., et al. (2004). Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control Versus Electrical Cardioversion (RACE) Study. Journal of the American College of Cardiology, 43(2), 241–247.

    Article  PubMed  Google Scholar 

  3. Viles-Gonzalez, J. F., & Mehta, D. (2011). Thromboembolic risk and anticoagulation strategies in patients undergoing catheter ablation for atrial fibrillation. Current Cardiology Reports, 13(1), 38–42.

    Article  PubMed  Google Scholar 

  4. Calkins, H., Kuck, K. H., Cappato, R., Brugada, J., Camm, A. J., Chen, S. A., et al. (2012). 2012 HRS/EHRA/ECAS Expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace, 14(4), 528–606.

    Article  PubMed  Google Scholar 

  5. Patel, A. A., Clyne, C. A., Henyan, N. N., White, C. M., Zembrowski, B. F., Migeed, M., et al. (2007). The use of protamine after radiofrequency catheter ablation: a pilot study. Journal of Interventional Cardiac Electrophysiology, 18(2), 155–158.

    Article  PubMed  Google Scholar 

  6. Conte, G., de Asmundis, C., Baltogiannis, G., Di Giovanni, G., Ciconte, G., Sieira, J., et al. (2014). Periprocedural outcomes of prophylactic protamine administration for reversal of heparin after cryoballoon ablation of atrial fibrillation. Journal of Interventional Cardiac Electrophysiology, 41(2), 129–134.

    Article  PubMed  Google Scholar 

  7. Camm, A. J., Lip, G. Y., De Caterina, R., Savelieva, I., Atar, D., Hohnloser, S. H., et al. (2012). 2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation developed with the special contribution of the European Heart Rhythm Association. Europace, 14(10), 1385–1413.

    Article  PubMed  Google Scholar 

  8. Aytemir, K., Gurses, K. M., Yalcin, M. U., Kocyigit, D., Dural, M., Evranos, B., et al. (2014). Safety and efficacy outcomes in patients undergoing pulmonary vein isolation with second-generation cryoballoon†. Europace. 2014 Nov 5. pii: euu273. [Epub ahead of print].

  9. Garcia, D. A., Baglin, T. P., Weitz, J. I., Samama, M. M., & American College of Chest, P. (2012). Parenteral anticoagulants: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141(2 Suppl), e24S–e43S.

    CAS  PubMed Central  PubMed  Google Scholar 

  10. Cappato, R., Calkins, H., Chen, S. A., Davies, W., Iesaka, Y., Kalman, J., et al. (2010). Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. Arrhythmia and Electrophysiology, 3(1), 32–38.

    Article  PubMed  Google Scholar 

  11. Gaita, F., Caponi, D., Pianelli, M., Scaglione, M., Toso, E., Cesarani, F., et al. (2010). Radiofrequency catheter ablation of atrial fibrillation: a cause of silent thromboembolism? Magnetic resonance imaging assessment of cerebral thromboembolism in patients undergoing ablation of atrial fibrillation. Circulation, 122(17), 1667–1673.

    Article  PubMed  Google Scholar 

  12. Neumann, T., Kuniss, M., Conradi, G., Janin, S., Berkowitsch, A., Wojcik, M., et al. (2011). MEDAFI-Trial (Micro-embolization during ablation of atrial fibrillation): comparison of pulmonary vein isolation using cryoballoon technique vs. radiofrequency energy. Europace, 13(1), 37–44.

    Article  PubMed  Google Scholar 

  13. Herrera Siklody, C., Deneke, T., Hocini, M., Lehrmann, H., Shin, D. I., Miyazaki, S., et al. (2011). Incidence of asymptomatic intracranial embolic events after pulmonary vein isolation: comparison of different atrial fibrillation ablation technologies in a multicenter study. Journal of the American College of Cardiology, 58(7), 681–688.

    Article  PubMed  Google Scholar 

  14. January, C. T., Wann, L. S., Alpert, J. S., Calkins, H., Cigarroa, J. E., Cleveland, J. C., Jr., et al. (2014). 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology, 64(21), 2246–2280.

    Article  Google Scholar 

  15. Abhishek, F., Heist, E. K., Barrett, C., Danik, S., Blendea, D., Correnti, C., et al. (2011). Effectiveness of a strategy to reduce major vascular complications from catheter ablation of atrial fibrillation. Journal of Interventional Cardiac Electrophysiology, 30(3), 211–215.

    Article  PubMed  Google Scholar 

  16. Hoyt, H., Bhonsale, A., Chilukuri, K., Alhumaid, F., Needleman, M., Edwards, D., et al. (2011). Complications arising from catheter ablation of atrial fibrillation: temporal trends and predictors. Heart Rhythm, 8(12), 1869–1874.

    Article  PubMed  Google Scholar 

  17. Cappato, R., Calkins, H., Chen, S. A., Davies, W., Iesaka, Y., Kalman, J., et al. (2005). Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation, 111(9), 1100–1105.

    Article  PubMed  Google Scholar 

  18. Di Biase, L., Burkhardt, J. D., Mohanty, P., Sanchez, J., Horton, R., Gallinghouse, G. J., et al. (2010). Periprocedural stroke and management of major bleeding complications in patients undergoing catheter ablation of atrial fibrillation: the impact of periprocedural therapeutic international normalized ratio. Circulation, 121(23), 2550–2556.

    Article  PubMed  Google Scholar 

  19. Lakkireddy, D., Reddy, Y. M., Di Biase, L., Vanga, S. R., Santangeli, P., Swarup, V., et al. (2012). Feasibility and safety of dabigatran versus warfarin for periprocedural anticoagulation in patients undergoing radiofrequency ablation for atrial fibrillation: results from a multicenter prospective registry. Journal of the American College of Cardiology, 59(13), 1168–1174.

    Article  CAS  PubMed  Google Scholar 

  20. Chilukuri, K., Henrikson, C. A., Dalal, D., Scherr, D., MacPherson, E. C., Cheng, A., et al. (2009). Incidence and outcomes of protamine reactions in patients undergoing catheter ablation of atrial fibrillation. Journal of Interventional Cardiac Electrophysiology, 25(3), 175–181.

    Article  PubMed  Google Scholar 

  21. Kuiper, K. K., & Nordrehaug, J. E. (2000). Early mobilization after protamine reversal of heparin following implantation of phosphorylcholine-coated stents in totally occluded coronary arteries. American Journal of Cardiology, 85(6), 698–702.

    Article  CAS  PubMed  Google Scholar 

  22. Pan, M., Suarez de Lezo, J., Medina, A., Romero, M., Hernandez, E., Segura, J., et al. (1997). In-laboratory removal of femoral sheath following protamine administration in patients having intracoronary stent implantation. American Journal of Cardiology, 80(10), 1336–1338.

    Article  CAS  PubMed  Google Scholar 

  23. Briguori, C., Di Mario, C., De Gregorio, J., Sheiban, I., Vaghetti, M., & Colombo, A. (1999). Administration of protamine after coronary stent deployment. American Heart Journal, 138(1 Pt 1), 64–68.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Cardiology, Hacettepe University Faculty of Medicine, 06100, Sihhiye, Ankara, Turkey

    Kadri Murat Gurses, Duygu Kocyigit, Muhammed Ulvi Yalcin, Banu Evranos, Hikmet Yorgun, Mehmet Levent Sahiner, Ergun Baris Kaya, Mehmet Ali Oto, Necla Ozer & Kudret Aytemir

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  1. Kadri Murat Gurses
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  2. Duygu Kocyigit
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  3. Muhammed Ulvi Yalcin
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Correspondence to Duygu Kocyigit.

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Gurses, K.M., Kocyigit, D., Yalcin, M.U. et al. Safety and efficacy outcomes of protamine administration for heparin reversal following cryoballoon-based pulmonary vein isolation. J Interv Card Electrophysiol 43, 161–167 (2015). https://doi.org/10.1007/s10840-015-9989-0

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  • DOI: https://doi.org/10.1007/s10840-015-9989-0

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