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Updated: May 2, 2026
Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Periprocedural stroke risk in patients undergoing catheter ablation for atrial fibrillation on uninterrupted warfarin
Stephen P Page1, Neil Herring, Ross J Hunter
1Barts Health NHS Trust, London, UK.
Insights
Catheter ablation for atrial fibrillation carries stroke risk. Uninterrupted warfarin (UW) showed a similar stroke rate to bridging heparin, with major deficits only in the heparin group. Optimal anticoagulation strategy remains unclear.
Area of Science:
- Cardiology
- Neurology
- Medical Procedures
Background:
- Atrial fibrillation (AF) catheter ablation is effective but risks periprocedural stroke.
- Uninterrupted warfarin (UW) may mitigate this risk, contrasting with bridging low-molecular-weight heparin (LMWH).
Purpose of the Study:
- To compare periprocedural stroke incidence, severity, and timing between UW and bridging LMWH protocols.
- To evaluate the safety and efficacy of different anticoagulation strategies during AF ablation.
Main Methods:
- Retrospective analysis of 2,855 ablations in 1,813 patients.
- Comparison of thromboembolic stroke rates between bridging LMWH and UW groups.
- Assessment of stroke severity, timing, and major bleeding complications.
Main Results:
- Stroke incidence was 0.7% with bridging LMWH vs. 0.4% with UW (P=0.5).
- All major neurological deficits occurred in the LMWH group; 80% of UW strokes were in low-risk patients.
- Major bleeding was higher in the LMWH group (6.0%) vs. UW group (4.0%, P=0.02).
Conclusions:
- Periprocedural stroke occurs even with therapeutic anticoagulation, challenging existing data.
- The optimal anticoagulation strategy to prevent stroke during AF ablation remains undetermined.
- Bridging LMWH was associated with more major neurological deficits compared to UW.
Background:
Catheter ablation is an effective treatment for symptomatic individuals with atrial fibrillation (AF) but is associated with a risk of periprocedual stroke. Recent data suggest that this risk may be abolished if catheter ablation is performed with uninterrupted warfarin (UW). We sought to compare the incidence, severity and timing of periprocedural stroke between 2 periprocedural anticoagulation protocols: bridging low-molecular-weight heparin (LMWH) and UW.
Methods And Results:
Periprocedural stroke (≤14 days) was assessed in 2,855 ablations performed in 1,813 patients. Thromboembolic stroke occurred in 11/1,653 (0.7%) procedures with bridging LMWH and in 5/1,202 (0.4%) procedures on UW (P = 0.5). Four of the 5 strokes (80%) on UW occurred despite a therapeutic INR and a mean activated clotting time of ≥300 seconds and 4/5 strokes (80%) occurred in patients with a CHADS2 score of 0. Eleven of 16 (69%) strokes overall occurred within 24 hours of the procedure. All 4 strokes resulting in major neurological deficit occurred in the LMWH group. Major bleeding complications occurred in 6.0% of patients in the bridging LMWH group compared to 4.0% in the UW group (P = 0.02).
Conclusions:
In contrast to existing data, periprocedural stroke still occurs despite therapeutic anticoagulation throughout the operative period. The optimal strategy to protect patients against thromboembolic stroke remains unclear.
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