Atrial fibrillation is a major cause of debilitating strokes and anticoagulation is an established and
indispensable therapy for reducing their rate. Ablation of the arrhythmia has emerged as a putative means of
disrupting its natural course by isolating its triggers and modifying its substrate, dependent on the chosen method.
An important dilemma lies in the need for continuation of anticoagulation therapy in those previously receiving it
following an, apparently, successful intervention, purportedly preventing arrhythmia recurrence with considerably
high rates. Current guidance, given scarcity of high-quality data from randomized trials, focuses on established
knowledge and recommends anticoagulation continuation based solely on estimated thromboembolic risk. In the
present review, it will be attempted to summarize the pathophysiological rationale for maintaining anticoagulation
post-successful ablation, along with the latter’s definition, including the two-fold effects of the procedure per se
on thrombogenicity. Available evidence pointing to an overall clinical benefit of anticoagulation withdrawal
following careful patient assessment will be discussed, including ongoing randomized trials aiming to offer definitive
answers. Finally, the proposed mode of post-ablation anticoagulation will be presented, including the
emerging, guideline-endorsed, role of direct oral anticoagulants in the field, altering cost/benefit ratio of anticoagulation
and potentially affecting the very decision regarding its discontinuation.
Keywords: Atrial fibrillation, ablation, anticoagulation, thromboembolic risk modulators, atrial myopathy, OCEAN trial, direct oral anticoagulants,
left atrial appendage closure.
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