Catheter Ablation for Atrial Fibrillation in Patients with Hemophilia or von Willebrand Disease

 

 Permissions and Reprints

Abstract

Background Management of atrial fibrillation (AF) is complex in patients with bleeding disorders. Catheter ablation such as pulmonary vein isolation (PVI) has been suggested in cases with bleeding disorders. However, data on safety are missing. This report describes the outcome of PVI in patients with bleeding disorders.

Methods A retrospective study in our hemophilia treatment center of patients who underwent a PVI in 2014 to 2018. PVI was done according to local protocol. Clotting factor was given periprocedural. Postprocedural anticoagulation was given for at least 4 weeks, with clotting factor suppletion if needed to maintain factor VIII (FVIII) levels >0.20 IU/mL.

Results and Discussion Five patients with hemophilia and one with von Willebrand disease were included. Eight PVIs were performed. Target FVIII levels (>0.80 IU/mL) were met before the procedure. Postprocedural anticoagulation was given: vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC) dabigatran. All patients obtained long-term sinus rhythm, in two patients after a second PVI. However, late recurrent AF occurred in one patient after 42 months. A notable incidence of groin bleeds was observed: two of eight interventions (25%) compared with 0.9% in the general population. Bleeding seemed to be related to agitation, early mobilization, and bridging of VKA with low molecular weight heparin (LMWH). No relevant bleeding was observed when on DOAC therapy.

Conclusion PVI seems to be effective in the case of bleeding disorders. To reduce the groin bleeds agitation and early mobilization should be avoided and DOAC is preferred over bridging VKA with LMWH.

Authors' Contributions

P.R. van der Valk performed the research, analyzed the data, and wrote the manuscript. J.F. van der Heijden wrote part of the of the manuscript, concerning the cardiac intervention, performed and supervised the PVIs. E.P. Mauser-Bunschoten supervised the manuscript. R.E.G. Schutgens designed the research and edited the manuscript.

• References

• 1 Hassan S, Monahan RC, Mauser-Bunschoten EP. , et al. Improved survival of patients with hemophilia in the Netherlands in the 21st century. Haemophilia 2019; 25 (Suppl. 01) 27-28
  CrossrefPubMedGoogle Scholar
• 2 Darby SC, Kan SW, Spooner RJ. , et al. Mortality rates, life expectancy, and causes of death in people with hemophilia A or B in the United Kingdom who were not infected with HIV. Blood 2007; 110 (03) 815-825
  PubMedGoogle Scholar
• 3 Plug I, Van Der Bom JG, Peters M. , et al. Mortality and causes of death in patients with hemophilia, 1992-2001: a prospective cohort study. J Thromb Haemost 2006; 4 (03) 510-516
  CrossrefPubMedGoogle Scholar
• 4 Kirchhof P, Benussi S, Kotecha D. , et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18 (11) 1609-1678
  CrossrefPubMedGoogle Scholar
• 5 Schutgens REG, Klamroth R, Pabinger I, Dolan G. ; ADVANCE working group. Management of atrial fibrillation in people with haemophilia--a consensus view by the ADVANCE Working Group. Haemophilia 2014; 20 (06) e417-e420
  CrossrefPubMedGoogle Scholar
• 6 Schutgens REG, Klamroth R, Pabinger I, Malerba M, Dolan G. ; ADVANCE working group. Atrial fibrillation in patients with haemophilia: a cross-sectional evaluation in Europe. Haemophilia 2014; 20 (05) 682-686
  CrossrefPubMedGoogle Scholar
• 7 Teunissen C, Kassenberg W, van der Heijden JF. , et al. Five-year efficacy of pulmonary vein antrum isolation as a primary ablation strategy for atrial fibrillation: a single-centre cohort study. Europace 2016; 18 (09) 1335-1342
  CrossrefPubMedGoogle Scholar
• 8 Tutuianu C, Szilagy J, Pap R, Sághy L. Very long-term results of atrial fibrillation ablation confirm that this therapy is really effective. J Atr Fibrillation 2015; 8 (02) 1226
  PubMedGoogle Scholar
• 9 Potpara TS, Larsen TB, Deharo JC. , et al; Scientific Initiatives Committee of European Heart Rhythm Association (EHRA). Oral anticoagulant therapy for stroke prevention in patients with atrial fibrillation undergoing ablation: results from the First European Snapshot Survey on Procedural Routines for Atrial Fibrillation Ablation (ESS-PRAFA). Europace 2015; 17 (06) 986-993
  CrossrefPubMedGoogle Scholar
• 10 Wazni OM, Beheiry S, Fahmy T. , et al. Atrial fibrillation ablation in patients with therapeutic international normalized ratio: comparison of strategies of anticoagulation management in the periprocedural period. Circulation 2007; 116 (22) 2531-2534
  CrossrefPubMedGoogle Scholar
• 11 Gopinath D, Lewis WR, Di Biase L, Natale A. Pulmonary vein antrum isolation for atrial fibrillation on therapeutic coumadin: special considerations. J Cardiovasc Electrophysiol 2011; 22 (02) 236-239
  PubMedGoogle Scholar
• 12 Cardoso R, Knijnik L, Bhonsale A. , et al. An updated meta-analysis of novel oral anticoagulants versus vitamin K antagonists for uninterrupted anticoagulation in atrial fibrillation catheter ablation. Heart Rhythm 2018; 15 (01) 107-115
  CrossrefPubMedGoogle Scholar
• 13 Pollack Jr CV, Reilly PA, van Ryn J. , et al. Idarucizumab for dabigatran reversal—full cohort analysis. N Engl J Med 2017; 377 (05) 431-441
  CrossrefPubMedGoogle Scholar
• 14 Schutgens RE, van der Heijden JF, Mauser-Bunschoten EP, Mannucci PM. New concepts for anticoagulant therapy in persons with hemophilia. Blood 2016; 128 (20) 2471-2474
  PubMedGoogle Scholar