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Electrophysiological Procedures in Patients with Coagulation Disorders ― a Systemic Review ―

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Electrophysiological Procedures in Patients with Coagulation Disorders ― a Systemic Review ― Advance Publication Circulation Journal REVIEW doi: 10.1253/circj.CJ-20-0078 Electrophysiological Procedures in Patients With Coagulation Disorders ― A Systemic Review ― Bartosz Krzowski, MD; Paweł Balsam, MD, PhD; Michał Peller, MD, PhD; Piotr Lodziński, MD, PhD; Marcin Grabowski, MD, PhD; Joanna Drozd-Sokołowska, MD, PhD; Grzegorz Basak, MD, PhD; Monika Gawałko, MD; Grzegorz Opolski, MD, PhD; Jedrzej Kosiuk, MD, PhD Catheter ablation (CA) is considered first-line treatment for many patients with symptomatic arrhythmias. Indications for CA are constantly increasing, as is the number of procedures. Although CA is nowadays regarded a safe procedure, there is a risk of com- plications, including both bleeding- and thrombosis-related events. Several factors contribute to periprocedural risk; of these, patient coagulation status is of considerable clinical relevance. In this context, even a simple procedure poses a considerable challenge in a patient with coagulation disorder. However, the level of evidence regarding CA in patients with coagulation disorders is very low. Neither experts’ recommendations nor clinical guidelines have been presented so far. The aim of this article is to analyze potential procedure-related risks and provide clinicians with useful information and practical suggestions regarding optimization of procedural safety in patients with coagulation disorders. Key Words: Bleeding; Cardiac arrhythmia; Catheter ablation; Coagulation disorders; Thrombosis n recent decades catheter ablation (CA) has become ing CA in patients with coagulation disorders is very low. the treatment of first choice for many patients with The aim of this review was to systematically analyze pos- I symptomatic arrhythmias. Aligned with constant sible procedural risks and pitfalls depending on the underly- improvements in CA techniques, indications for the proce- ing disease and provide clinical guidance based on the dure are constantly expanding.1 Thus, a further increase in available literature. Because of the number of coagulation the number of CA procedures is inevitable.2 CA is regarded disorders and the lack of data regarding CA in specific dis- as safe procedure, with low complication and high success orders, we focused on the most common coagulation dis- rates that are continually improving with increased experi- orders, namely heparin-induced thrombocytopenia (HIT), ence and new technological developments. Despite prog- hemophilia, heterozygous Factor V (FV) Leiden mutation, ress in the CA technique, the risk of complications remains von Willebrand Disease (vWD), light chain amyloidosis, a part of everyday practice, with bleeding and thrombosis antiphospholipid syndrome, myelodysplastic syndrome, being the most clinically relevant complications.3 However, immune-mediated disorders and hereditary hemorrhagic the ablation procedure is associated not only with a sig- telangiectasia. nificant bleeding risk, related to either vascular access or cardiac perforation, but also thrombus formation caused Methods by biophysical aspects of radiofrequency energy transmis- sion, increased tissue temperature, local endothelial dam- This systematic review was conducted in accord with the age, and the presence of catheters in the heart and vessels. Preferred Reporting Items for Systematic Reviews and The rate of adverse events depends strongly on physician Meta-Analyses (PRISMA) guidelines. experience, the technology used, and the type of the proce- A systematic search was performed of the PubMed data- dure.4 However, patient-related risk factors also contribute. base from inception to April 2019. The search strategy In particular, diseases that increase the tendency for bleeding focused on identifying studies and case reports that or thrombosis are particular challenges, and so specific steps described electrophysiological procedures in patients with should be undertaken in order to safely perform CA in coagulopathies. The reference lists of the included articles such patients. Unfortunately, the level of evidence regard- and other published reviews were also examined to identify Received February 6, 2020; revised manuscript received March 10, 2020; accepted March 25, 2020; J-STAGE Advance Publication released online April 29, 2020 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw (B.K., P.B., M.P., P.L., M. Grabowski, M. Gawałko, G.O., J.K.); Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw (J.D.-S., G.B.), Poland; and Department of Electrophysiology, Helios Klinikum Koethen, Koethen (J.K.), Germany Mailing address: Jedrzej Kosiuk, MD, PhD, Department of Electrophysiology, Helios Klinkum Koethen, Hallesche Strasse 29, 06366 Koethen, Germany. E-mail: [email protected] ISSN-1346-9843 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: [email protected] Advance Publication 2 KRZOWSKI B et al. any additional studies relevant to this review. HIT HIT is an adverse drug reaction, with 2 separate types: Inclusion and Exclusion Criteria Type I, a less dangerous and self-limiting type caused by Studies were included if they described the procedures of non-immune mechanisms; and Type II, a potentially lethal, CA or electrophysiological study (EPS) in patients with although rarer, type. The autoimmune-mediated response coagulation disorders a priori, or if coagulation disorder in Type II HIT is caused by the development of IgG anti- appeared as a complication after CA. Studies and case bodies directed against a complex consisting of heparin reports were excluded if: (1) they did not precisely describe and platelet factor 4 (PF4). In addition, platelets are acti- the periprocedural events; (2) they presented partial data; vated through their Fcg IIa receptors.5 HIT Type II is a and (3) the manuscript was not available for review in prothrombotic condition, manifesting both venous and English or was only available in abstract form. The decision arterial thrombosis. to exclude conference abstracts was based on the limita- Clinical Relevancy in the Setting of a CA Procedure tions in assessing the study quality of conference abstracts Although HIT is estimated to occur in 0.7–5% of patients alone and difficulties in extracting the required depth of receiving unfractionated heparin (UFH),6 electrophysiolo- information from such abstracts. gists should be aware of the possibility of HIT Type II fol- lowing the index procedure and must be capable of conducting Study Selection a safe CA procedure in patients with a history of HIT. Two reviewers (B.K., J.D.-S.) independently screened the The exact prevalence of HIT is difficult to establish, titles and abstracts of all publications identified and excluded because its incidence depends on several risk factors, such articles that were irrelevant to the topic. The reviewers then as duration of heparin therapy, heparin type (UFH > low evaluated the full text of eligible articles for suitability molecular weight heparin, bovine > porcine), type of pro- based on the strict inclusion and exclusion criteria. A third cedure (surgical > medical patients), and sex (female > male).7 reviewer (J.K.) was used to resolve discrepancies. The main clinical manifestations of HIT Type II are deep vein thrombosis (DVT), pulmonary embolism (PE), Results and Discussion arterial thrombosis (including limb artery thrombosis), thrombotic stroke, myocardial infarction, and necrotizing The data collected from 18 studies and case reports is sum- skin lesions at heparin injection sites.6,7 The typical HIT- marized in Table. The sections below discuss specific coag- associated fall in platelet count is >50% and occurs 5–10 ulopathies in detail. days after starting heparin. An earlier onset of HIT may be observed if the patient has Table. Summary of Publications Reporting Electrophysiological Procedures in Patients With Coagulopathies Publication type Description Conclusions HIT Case report10 Bivalirudin use during CA (VT, PVI) in 2 patients with HIT Bivalirudin is a therapeutic option for history; no complications observed anticoagulation during CA in patients with HIT history Case report11 Bivalirudin use during cryoballoon ablation (PVI) in a Bivalirudin in conjunction with apixaban is an patient with HIT history option during cryoballoon ablation in patients with HIT history Case report12 Bivalirudin use during CA (PVI) in a patient with HIT history; Bivalirudin is a therapeutic option for no complications observed anticoagulation during CA in patients with HIT history Case report13 Bivalirudin use during CA (VT) in a patient with HIT history; Bivalirudin is safe in patients with HIT and no complications observed renal failure during CA Case report17 HIT as a complication after CA procedure (SVT) Patients undergoing CA are at risk of HIT Case report18 Atypical HIT presentation in a patient 5 months after short Rare presentation of HIT can occur during CA exposure to LMWH; thrombus attached to ablation catheter during CA (PVI) with subsequent HIT confirmation Case report19 Ischemic stroke 36 h after CA (PVI) due to HIT-related Attention should be paid to DVT in patients venous thrombosis and iatrogenic right-to-left shunt undergoing CA in order to reduce stroke risk Hemophilia Case report37 12-year-old male with mild hemophilia A Continuous recombinant Factor VIII infusion underwent successful cryoablation because provides sufficient coagulation status to of AVNRT; no complications observed undergo CA Case series38 Summary
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