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Optimal anticoagulation strategy for atrial fibrillation ablation: are all direct oral anticoagulants and vitamin K antagonists the same? - a meta-analysis of embolic and bleeding complications in more than 31,500 patients Cover

Optimal anticoagulation strategy for atrial fibrillation ablation: are all direct oral anticoagulants and vitamin K antagonists the same? - a meta-analysis of embolic and bleeding complications in more than 31,500 patients

Romanian Journal of Cardiology
Volume 35 (2025): Issue 2 (June 2025)
By: Dan L Musat,  Bogdan Enache,  Alexandra Musat,  Advay Bhatt,  Mohammadali Habibi,  Stephanie Kochav,  Tina Sichrovsky,  Mark W Preminger and  Suneet Mittal  
Open Access
|Jun 2025

Figures & Tables

Figure 1

Studies selection Stratagem.
Studies selection Stratagem.

Figure 2

Funnel Plot for publication bias.
Funnel Plot for publication bias.
Central Figure.
Central Figure.

Figure 3

Total Complications – Entire Cohort.
Total Complications – Entire Cohort.

Figure 4

Thromboembolic Complications – Entire Cohort.
Thromboembolic Complications – Entire Cohort.

Figure 5

Total Bleeding Complications – Entire Cohort.
Total Bleeding Complications – Entire Cohort.

Figure 6

Major (A) and Minor (B) Bleeding Complications – Entire Cohort.
Major (A) and Minor (B) Bleeding Complications – Entire Cohort.

Figure 7

Complications Uninterrupted DOACS vs. Uninterrupted VKA.
Complications Uninterrupted DOACS vs. Uninterrupted VKA.

Figure 8

Complications Interrupted DOACS vs. Uninterrupted VKA.
Complications Interrupted DOACS vs. Uninterrupted VKA.

Figure 9

Complications DOACS vs. Interrupted VKA.
Complications DOACS vs. Interrupted VKA.

Figure 10

Complications DOACS vs non-Warfarin VKA.
Complications DOACS vs non-Warfarin VKA.

Figure 11

Bleeding and Thromboembolic Complications of Dabigatran, Rivaroxaban, Apixaban Compared to VKA.
Bleeding and Thromboembolic Complications of Dabigatran, Rivaroxaban, Apixaban Compared to VKA.

Studies’ Characteristics_

No.Author Journal, YearYearNo. of centersStudy periodType of studyGRADE Quality RatingNumber of patients
TotalDOACDRAEUVKAIVKA
1Armbruster HL et al. Annals of Pharm 201520151Jan 2012-Dec 2013Retrospective analysisModerate3742011236117 173
2Arshad A et al. PACE 201420144Oct 2010-Oct 2012Retrospective analysisModerate882374374 276232
3Bassiouny M et al. Circ Arrhythmia EP 201320131Dec 2010-Jul 2012Prospective registryModerate999376376 623
4Calkins H et al. NEJM 20172017104April 2015-July 2016Prospective randomizedHigh635317317 318
5Cappato R et al. European Heart Journal 2015201537Feb 2013-Sep 2014Prospective randomizedHigh248124 124 124
6De Heide J et al. J Int Card Electrophys 201820181Jan 2013-Apr 2017Retrospective analysisLow6371176814305520
7DiBiase L et al. Heart Rhythm 201520154June 2013-July 2014Prospective match cohortHigh400200 200 200
8Dillier R et al. Circ Arrhythmia EP 201420141Feb 2012 May 2013Retrospective analysis-matchedModerate544272 272 272
9Efremidis M et al. J of Electrocardiology 201520151June 2013-Sep 2014Prospective registryModerate1496464 85
10Enriquez AD et al. PACE 201720171Jan 2013-Nov 2014Retrospective analysisLow471258 258 213
11Garcia LI et al. J Afib 201420141Jul 2011-Oct 2012Retrospective analysisLow325126126 199
12Gjermeni D et al. European Heart Journal 202320231Jan 2011 May 2017Retrospective analysisModerate22191290697399194 929
13Gunawardene et al. Clin Res Cardiol 201720171Jan 2011-Dec 2014Retrospective analysisModerate144044114725341 488511
14Haines DE et al. J Int Card Electrophys 201320134Nov 2010-Nov 2011Retrospective analysisLow404202202 16240
15Hohnloser SH et al. European Heart Journal 2019201958March 2017-Sep 2018Prospective randomizedHigh553375 375178
16Ichiki H et al. PACE 201320131Apr 2010-Jul 2012Prospective registryLow2373636 201
17Imamura K et al. J Int Card Electrophys 201320131Apr 2011-Nov 2012Prospective analysisModerate227101101 126
18Kaess BM at al. Am J Cardiol 201520151Mar 2014Retrospective case matchedModerate315105 105 210
19Kaiser D et al. J Int Card Electrophys 201320131Jan 2011-Aug 2012Retrospective analysisLow257122122 135
20Kaseno K et al. Circ Journal Jap 201220121Apr 2011-Jan 2012Retrospective analysisModerate211110110 101
21Kim JS et al. Heart Rhythm 201320131Jan 2011-Aug 2012Case-control analysisModerate763191191 572
22Kimura T et al. JACC 201820182Jul 2014-Jan 2016Prospective randomizedHigh12764 64 63
23Kirchhof P et al. European Heart Journal 2018201849Feb 2015-Apr 2017Prospective randomizedHigh633318 318 315
24Kochhauser S et al. Can J of Card 201420141Oct 2010-Oct 2013Retrospective analysisModerate680361220141 319
25Koetkuerk B et al. Cardiovasc Therap 201620161Aug 2012 May 2015Retrospective analysisModerate4092594819318 150
26Konduru SV et al. J Int Card Electrophys 201220121Jan 2011-Aug 2011Retrospective analysisModerate762424 52
27Kuwahara T et al. J of Card Electrophys 201620163NRProspective randomizedHigh200100 100 100
28Lakkireddy D et al. JACC 201220128Jan 2010-Jul 2011Prospective registryModerate290145145 145
29Lakkireddy D et al. JACC 201420148Jan 2012-Mar 2013Prospective registryModerate642321 321 321
30Lin J et al. J Afib 201420141Jan 2010-Dec 2012Retrospective analysisLow324181181 143
31Maddox W et al. J Card Electrophysiol 201320131Nov 2010-Jan 2012Retrospective analysisLow463212212 251
32Mugnai G et al. American J of Card 201720172Jun 2013-Sep 2015Retrospective analysisModerate454164607133 290
33Muller P et al. J Interv Card Electro 201620161NRProspective cohortModerate192106 4343
34Murakawa Y et al. J of Arrhythmia 20152015179Sep 2011-Sep2012Retrospective surveyLow234954150437 1808
35Nagao T et al. Heart Rhythm 201520151April 2012 Aug 2014Retrospective analysisModerate869499239102158 370
36Nagao T et al. PACE 201520151April 2013 Mar 2014Retrospective analysisModerate342105 105 237
37Nagao T et al. Internal Med 201520151April 2012 Nov 2013Retrospective analysisModerate363173173 190
38Nin T et al. PACE 201320131Apr 2011 May 2012Prospective randomizedHigh904444 46
39Nogami A et al. JAMA 2019201928May 2014-Sep 2015Prospective randomizedHigh442220220 222
40Okishige K et al. J of Card 201720171NRProspective registryModerate2572386681306119
41Reynolds MR et al. JACC EP 2018201818Dec 2015-Jan 2017Retrospective analysisModerate590295 295 295
42Rilling A et al. JCE 201620161Oct 2013-Oct 2014Prospective registryModerate4443245119380 120
43Snipelisky D et al. J Int Card Electrophys 201220121Jan 2011-Dec 2011Retrospective analysisLow1563131 125
44Snipelisky D et al. J Int Card Electrophys 201420141Jan 2011 -2014Retrospective analysisModerate2171309040 87
45Somani R et al. Cardiovasc Therap 201420141Nov 2010-Jan 2012Retrospective analysisModerate2074343 9569
46Stepanyan G et al. J Int Card Electrophys 201420141Jan 2011-Sep 2013Retrospective analysisModerate3011878998 114
47Tang l et al. Frontiers in Med 202020201Jan 2010-Dec 2018Retrospective analysisLow452018768651011 7961848
48Tao S et al. J Int Card Electroph 201720171Nov 2012-Mar 2014Prospective cohortModerate14776 76 71
49Tscholl V et al. Clinical Cardio 201720171NRRetrospective analysisLow200153316755 47
50Vlachos K et al. Clinical Cardio 201720171June 2013-Dec 2016Prospective cohortModerate474338114110114 136
51Yamaji H et al. Clin Drug Inv 201320131Mar 2009-Dec 2011Retrospective analysisModerate503106106 203194
52Yanagisawa S et al. JACC Clin Electrpph 201820181Jan 2009-Jun 2017Retrospective analysisModerate21641129333228514541035
53Yoshimura et al. Journal of Card 201720171Mar 2013-Dec 2014Prospective randomizedHigh174105 5550 69

Patients Baseline Characteristics, *p value < 0_05; W – warfarin; BMI – body mass index; TIA - transient ischemic attack; LVEF – left ventricular ejection fraction; LA – left atrium; NR – not reported_

No.AuthorAge (yrs)Male (%)BMIPrior stroke/TIA (%)CHADS2CHA2DS2-VAScParox AF (%)LVEF (%)LA dimension
DOACVKADOACVKADOACVKADOACVKADOACVKADOACVKADOACVKADOACVKADOACVKA
1Armbruster HL et al.60 ± 1064 ± 10*767230 ± 629 ± 7611NRNR≥ 2 - 51 %≥ 2 - 66 %NRNRNRNRNRNR
2Arshad A et al.61 ± 1262 ± 11716729 ± 631 ± 6*1081.1 ± 1.11.3 ± 1.2*NRNR566056 ± 1055 ± 1045 ± 9 mm44 ± 8 mm
3Bassiouny M et al.59 ± 1163 ± 10*757330 ± 531 ± 668≥ 2 - 20 %≥ 2 - 29 %*NRNR5755555532 ml/m234 ml/m2
4Calkins H et al59 ± 1059 ± 107377292933NRNR22.26769NRNRNRNR
5Cappato et al.59 ± 1060 ± 10697330 ± 629 ± 6020.7 + 0.70.8 ± 0.91.5 ± 1.31.5 ± 1.37770NRNRNRNR
6DiBiasi L et al.66 ± 1066 ± 1071.571.529 ± 630 ± 6651.3 ± 0.91.3 ± 0.82.3 ± 1.42.3 ± 1.416.516.556 ± 957 ± 1145 ± 8 mm45 ± 9 mm
7De Heide J et al.60 ± 960 ± 10726827 ± 328 ± 4NRNRNRNR≥ 2 - 34 %≥ 2 - 47 %7476NRNR43 ± 742 ± 6
8Dillier R at al.62 ± 1164 ± 10686827 ± 427 ±4670.9 ± 0.81.0 ± 0.91.8 ± 1.42.0 ± 1.5494660 ± 3756 ± 744 ± 645 ± 7
9Efremidis et al.57 ± 1258 ± 9706927 ± 327 ± 3NRNR0.7 ± 0.80.8 ± 0.91.1 ± 1.11.2 ± 1.2656361 ± 659 ± 6NRNR
10Enriquez AD et al61 ± 1060 ± 107172NRNRNRNRNRNR1.6 ± 1.41.9 ± 1.36553NRNRNRNR
11Garcia LI et al.62 (55-69)65 (58-72)*726631 ± 630 ± 79190.98 ± 1.51.2 ± 1.4*2.1 ± 0.32.7 ± 0.2*282957 ± 1055 ± 10NRNR
12Gjermeni D. et al.62 ± 1065 ± 10696428 ± 529 ± 7710NRNR≥ 2 - 42 %≥ 2 - 58 %7665NRNRNRNR
13Gunawardene el al.64 ± 1064 ± 10716627 ± 427 ± 49121 (1;2)1 (1;2)2 (1;3)2 (1;3)0057 ± 858 ± 8NRNR
14Haines DE et al.60 ± 1060 ± 117469NRNR79NRNR1.6 ± 1.31.9 ± 1.4585256 ± 1057 ± 944 ± 7 mm44 ± 9 mm
15Hohnloser SH et al.60 (53-67)61 (52-67)717328(25–31)28(26–31)55NRNR≥ 2 - 50 %≥ 2 - 50 %6869NRNRNRNR
16Ichiki H et al.57 ± 1160 ± 108378NRNRNRNR1.1 ± 1.11.0 ± 1.0NRNR7050*65 ± 864 ± 1165 ± 24 ml/m270 ± 24 ml/m2
17Imamura K et al.61 ± 1062 ± 87571NRNR680.9 ± 0.91.1 ± 1.01.6 ± 1.21.8 ± 1.2564963 ± 862 ± 941 ± 7 mm42 ± 7 mm
18Kaess BM et al.63 ± 1264 ± 10676727 ± 527 ± 4871.2 ± 1.11.0 ± 0.92.1 ± 1.82.0 ± 1.5545458 ± 756 ± 644 (39,49)44 (40,49)
19Kaiser D et al.58 ± 1164 ± 10*646831 ± 631 ± 6761.2 ± 11.6 ± 1*1.8 ± 1.42.5 ± 1.4*69*4762 ± 8*59 ± 1138 ± 9 mm43 ± 8 mm
20Kaseno K et al.59 ± 1062 ± 8757924 ± 324 ± 445≥ 2 - 8%≥ 2 - 14%NRNR83*5564 ± 1063 ± 1039 ± 6 mm43 ± 7 mm
21Kim JS et al.61 ± 1061 ± 10807431 ± 632 ± 6381.0 ± 0.91.1 ± 1.01.6 ± 1.31.7 ± 1.3534858 ± 957 ± 1143 ± 7 mm44 ± 7 mm
22Kimura T et al.59 (52-65)62 (53-67)535324(22–25)24(22–26)NRNRNRNRNRNR636756(51-58)56(52-57)39 (35-42.5)37 (33-43) mm
23Kirchhof P et al.64 (57,70)64 (58,70)696528(25,32)28(26,32)7.57.3NRNR2.4(1.2)2.4(1.2)NRNRNRNRNRNR
24Kochhauser S et al.60 ± 1062 ± 117673NRNRNRNR0.9 ± 0.60.8 ± 0.51.5 ± 0.81.4 ± 0.87469NRNR41 ± 5 mm42 ± 6 mm
25Koetkuerk B et al.61 ± 1062 ± 106253NRNRNRNRNRNR1.5 ± 1.02.1 ± 1.562*4761 ± 1058 ± 933 ± 11 mm35 ± 13 mm
26Konduru SV et al.57 ± 1061 ± 107967NRNR00NRNRNRNR7956NRNRNRNR
27Kuwahara T et al.65 ± 966 ± 87572NRNRNRNRNRNR2.1 ± 1.32.4 ± 1.4596064 ± 962 ± 941 ± 7 mm42 ± 6 mm
28Lakkireddy D at al.60 ± 1060 ± 107979NRNR36≥ 2 - 23%≥ 2 - 19%1.6 ± 1.41.5 ± 1.3575756 ± 1056 ± 1045 ± 25 mm44 ± 8 mm
29Lakkireddy D et al.63 ± 1063 ± 10696930 ± 630 ± 61181.2 ± 11.2 ± 12.2 ± 1.62.2 ± .2515158 ± 857 ± 844 ± 8 mm43 ± 8 mm
30Lin J et al.60 ± 960 ± 108075NRNR58≥ 2 - 13%≥ 2 - 25%*NRNR7569NRNRNRNR
31Maddox W et al.62 ± 1263 ± 1076*67NRNR440.9 ± 0.90.9 ± 0.91.7 ± 1.51.7 ± 1.3635753 ± 454 ± 5NRNR
32Mugnai G et al.63 ± 10*59 ± 11727127 ± 427 ± 5NRNRNRNR1.8 ± 1.31.5 ± 1.3NRNR57 ± 958 ± 744 ± 9 mm44 ± 9 mm
33Muller P et al.63 ± 164 ± 26458NRNR510NRNR2.3 ± .22.2 ± 1.3445858 ± 157 ± 144 ± 1 mm44 ± 1 mm
34Murakawa Y et al.60 ± 1163 ± 10*7676NRNRNRNRNRNR1.5 ± 1.31.9 ± 1.5*70*6165 ± 9*63 ± 1040 ± 6 mm41 ± 6* mm
35Nagao T et al.60 ± 1261 ± 11747424 ± 324 ± 3550.8 ± 10.8 ± 0.91.5 ± 1.51.5 ± 1.5757362 ± 861 ± 939 ± 7 mm40 ± 7 mm
36Nagao T et al.61 ± 1362 ± 8737324 ± 424 ± 4660.8 ± 1.10.8 ± 0.9NRNR768162 ± 962 ± 937 ± 6 mm40 ± 2 mm
37Nagao T et al.59 ± 1359 ± 9777724 ± 424 ± 3450.6 ± 0.90.7 ± 0.91.2 ± 1.21.3 ± 1.4726462 ± 761 ± 738 ± 6 mm39 ± 7 mm
38Nin T et al.3661 ± 1161 ± 6848024 ± 424 ± 3411≥ 2 - 18%≥ 2 - 20%NRNR767161 ± 762 ± 839 ± 7 mm40 ± 8 mm
39Nogami A et al.65(59-71)66(59-71)787224(22-26)24(22-26)75NRNR2 (1-3)2 (1-3)636266(60-71)65(60-70)NRNR
40Okishige K et al.64 ± 1265 ± 1168742425NRNR1 ± 11.9 ± 1*NRNRNRNR64 ± 1068 ± 840 ± 7 mm42 ± 6 mm
41Reynolds MR et al.64 ± 1064 ± 10676831 ± 632 ± 7*35NRNR2.3 ± 1.62.6 ± 1.5656457 ± 955 ± 10NRNR
42Rilling A et al.65 ± 1067 ± 11586628 ± 1428 ± 4711NRNR2 (1,3)3 (2,4)*4043NRNRNRNR
43Snipelisky D et al.61658174NRNRNRNR0.841.22NRNR6846NRNRNRNR
44Snipelisky D et al.6666696229308511.4NRNRNRNRNRNRNRNR
45Somani R et al.60 ± 1062 ± 88477NRNR270.6 ± 0.70.8 ± 0.9NRNR7066NRNR34 ± 13 ml/m239 ± 12 ml/m2
46Stepanyan G et al.60 ± 1163 ± 106267NRNR710≥ 2 - 7%≥ 2 - 7%NRNR77*63NRNRNRNR
47Tang l et al.59 ± 1158 ± 116666NRNR76NRNR≥ 2 - 44 %≥ 2 - 43 %8079NRNRNRNR
48Tao S et al.66 ± 966 ± 11746624 ± 424 ± 41171.3 ± 11.5 ± 1.12.2 ± 1.32.5 ± 1.5727767 ± 864 ± 1140 ± 5 mm41 ± 6 mm
49Tscholl V et al.63 ± 168 ± 9*594728 ± 630 ± 564NRNR2.6 ± 1.73.1 ± 1.2533864 ± 864 ± 743 ± 3 mm42 ± 7 mm
50Vlanchos K et al.58 ± 1259 ± 10687028 ± 1432 ± 40NRNRNRNR1.3 ± 1.21.4 ± 1.1655860 ± 759 ± 7NRNR
51Yamaji H et al.60 ± 862 ± 87576NRNR54NRNR1.8 ± 1.61.7 ± 1.5656260 ± 660 ± 843 ± 6 mm41 ± 5 mm
52Yanagisawa et al.63 ± 863 ± 8737524 ± 524 ± 4791.1 ± 11.1 ± 11.9 ± 1.31.9 ± 1.2686862 ± 860 ± 1039 ± 7 mm40 ± 7 mm
53Yoshimura et al.59 ± 1161 ± 8827524 ± 425 ± 414101.1 ± 1.11.0 ± 1.01.7 ± 1.41.5 ± 1.3615164 ± 964 ± 942 ± 6 mm44 ± 6 mm

Anticoagulation Characteristics; D – dabigatran; R – rivaroxaban; W – warfarin; N/A -not applicable; NR – not reported; CW – continuous warfarin; TEE – transesophageal echocardiogram; UFH – unfractionated heparin; LMWH – low molecular weight heparin

No.AuthorPre procedure anticoagulationAntiplatelets (%)DOACVKA TypeVKA bridging protocolINR (CVKA)Pre-procedureTEE
DOACVKADOACVKAStop preStart postPrePostDOACVKA
1Armbruster HL et al. Annals of Pharm 2015NRNR20273 doses D 1-2 doses R4h post procedureWarfarinUninterrupted2.6 ± 0.7For persistent AFFor persistent AF
2Arshad A et al. PACE 2014≥ 4 weeks≥ 4 weeks28.6*16.112-48 hEvening of procedureWarfarinUninterrupted or W stopped 5 days with LMWHW night of procedure; LMWH 0.5-0.6 mg/kg2.4 ± 0.4TEE at 3/4 centers; as needed 1/4 centersTEE at 3/4 centers;as needed 1/4 centers
3Bassiouny M et al. Circ Arrhythmia EP 2013≥ 4 weeks≥ 4 weeks3339*12-24 hImmediate post-procedureWarfarinUninterrupted2.4As needed 12%As needed 25%*
4Calkins H et al. NEJM 2017≥ 4 weeks≥ 4 weeks1923UninterruptedUninterruptedWarfarinUninterrupted2.3100%100%
5Cappato R et al. European Heart Journal 2015≥ 3 weeks or 1-7 days - TEE or ICE≥ 3 weeks or 1-7 days - TEE or ICE3023Uninterrupted VKAUninterruptedNRIf necessaryIf necessary
6De Heide J et al. J Int Card Electrophys 2018≥ 3 weeks≥ 3 weeksNRNR>24h; 1-2 doses heldEvening of procedureMarcoumar AcenocoumarolUninterruptedNR100%100%
7DiBiase L et al. Heart Rhythm 2015≥ 3 weeks≥ 3 weeks30.538.5UninterruptedUninterruptedWarfarinUninterrupted2.5 ± 0.5Not mandatedPatients in AF and INR < 2.0
8Dillier R et al. Circ Arrhythmia EP 2014≥ 4 weeks≥ 4 weeks1615Uninterrupted12- 22 hPhenprocoumonUninterrupted2.1 ± 0.4100% TEE or CT100% TEE or CT
9Efremidis M et al. J of Electrocardiology 2015≥ 3 weeks≥ 3 weeksNRNR24hImmediate post-procedureAcenocoumarolUninterrupted2.4 ± 0.2100%100%
10Enriquez AD et al. PACE 2017NRNRNRNRUninterruptedUninterruptedWarfarinUninterrupted2.3 ± 0.4NRNR
11Garcia LI et al. J Afib 2014NRNR152396 hNext AM with LMWH 0.5 mg/kg × 3 doses; UFH IV 4-6h postWarfarinUninterrupted2.2 (1.8-2.5)100%100%
12Gjermeni D et al. European Heart Journal 2023NRNRNRNR<48h (prior to 2015) post 2015- uninterruptedEvening of procedurePhenprocoumonUninterruptedNRAt physician discretionAt physician discretion
13Gunawardene et al. Clin Res Cardiol 2017NRNRNRNR48 hEvening of procedureVKAUninterrupted or LMWHUninterrupted or LMWHNR100%100%
14Haines DE et al. J Int Card Electrophys 2013NRNR6547<12-48 h 22% bridge LMWH12 ± 10 hWarfarinUninterrupted in 80% LMWH bridgeLMWH2.3 ± 0.7Pts not on continuous ACPts not on continuous AC
15Hohnloser SH et al. European Heart Journal 2019≥ 3 weeks≥ 3 weeksNRNRUninterruptedUninterruptedVKAUninterruptedNR100% TEE or ICE100% TEE or ICE
16Ichiki H et al. PACE 2013NRNRNRNRMorning of procedureEvening of procedureWarfarinUninterrupted1.99 ± 0.6100%100%
17Imamura K et al. J Int Card Electrophys 2013≥ 4 weeks≥ 4 weeks8724 h for CHADS 0-1; 12 h CHADS >13h post-procedureWarfarinW stopped 3 days; UFH bridgeUFH + W 3 h post procedureN/A100%100%
18Kaess BM at al. Am J Cardiol 2015≥ 4 weeks≥ 4 weeks2215UninterruptedUninterruptedPhenprocoumonUninterrupted2.1 ± 0.4100% TEE or CT100% TEE or CT
19Kaiser D et al. J Int Card Electrophys 2013NRNR585124-30 h CrCl > 50 ml/min 3-5 days CrCl 15-30 ml/minImmediate post-procedureWarfarinUninterruptedUninterrupted; 24% UFH bridge≥ 1.5S-TEE per operator; AF-TEE 100%AF-TEE 100%
20Kaseno K et al. Circ Journal Jap 201226 ± 43 days≥ 4 weeksNRNRMorning of procedureMorning after procedure 10000 UFH first 24hWarfarinUninterruptedUninterrupted + 10000 UFH first 24h2.4 ± 0.4100%100%
21Kim JS et al. Heart Rhythm 2013≥ 4 weeks≥ 4 weeks364324-30 hImmediate post-procedureWarfarinUninterrupted2.4 ± 0.3100%100%
22Kimura T et al. JACC 2018≥ 4 weeks≥ 4 weeksNRNRUninterruptedUninterruptedWarfarinUninterrupted2.2 (1.7-2.8)100%100%
23Kirchhof P et al. European Heart Journal 2018≥ 4 weeks≥ 4 weeks3.56UninterruptedUninterruptedVKAUninterruptedNR87%87%
24Kochhauser S et al. Can J of Card 2014≥ 4 weeks≥ 4 weeksNRNR> 24 h8 hWarfarinW stopped 4 days, LMWH bridge 2 daysW night of procedure + LMWH bridgingNR100%100%
25Koektuerk B et al. Cardiovasc Therap 2016NRNRNRNR24 hEvening of procedurePhenprocoumonUninterruptedNR100%100%
26Konduru SV et al. J Int Card Electrophys 2012NRNR5429*Uninterrupted or 24 hEvening of procedureWarfarinUninterrupted2.2 ± 0.3100%100%
27Kuwahara T et al. J of Card Electrophys 2016≥ 30 days≥ 30 daysNRNRUninterruptedUninterruptedWarfarinUninterrupted2.2 ± 0.6NRNR
28Lakkireddy D et al. JACC 2012≥ 4 weeks≥ 4 weeks3434Morning of procedure3 h post hemostasisWarfarinUninterrupted2.0-3.5100%none
29Lakkireddy D et al. JACC 2014≥ 4 weeks≥ 3 weeks3126Uninterrupted≥ 3 h post hemostasisWarfarinUninterrupted2.3 ± 0.4100%Only for low INR
30Lin J et al. J Afib 2014NRNRNRNR36 hMorning after procedureWarfarinW stopped 3-5 days; LMWH bridgeW night of, LMWH morning post procedureN/AMost of patientsMost of patients
31Maddox W et al. J Card Electrophysiol 2013≥ 4 weeks≥ 4 weeksNRNRUninterruptedUninterruptedWarfarinUninterrupted2.3 ± 0.5100%100%
32Mugnai G et al. American J of Card 2017NRNRNRNR> 24-36 hEvening of procedureWarfarin AcenocoumarolW stopped > 24 h, if INR<2, bridged w LMWHLMWH same day of procedureNR100%100%
33Muller P et al. J Interv Card Electro 2016NRNRNRNRUninterrupted or 24 hEvening of procedureVKAVKA stopped 5-7 days, bridged w LMWHheparin infusion 4 h initial and LMWH day after procedureNR100%100%
34Murakawa Y et al. J of Arrhythmia 2015NRNRNRNR0-24hNRWarfarinUninterruptedNRNRNR
35Nagao T et al. Heart Rhythm 2015≥ 4 weeks≥ 4 weeks97UninterruptedUninterruptedWarfarinUninterruptedNR100%100%
36Nagao T et al. PACE 2015≥ 4 weeks≥ 4 weeks1111UninterruptedUninterruptedWarfarinUninterrupted2.2 ± 0.5100%100%
37Nagao T et al. Internal Med 2015≥ 4 weeks≥ 4 weeks99UninterruptedUninterruptedWarfarinUninterrupted2.2 ± 0.5100%100%
38Nin T et al. PACE 2013≥ 3 weeks≥ 3 weeksNRNR> 24 hImmediate post-procedureWarfarinW stopped > 24 h≥ 4 h post procedure hemostasis1.8 ± 0.4100%100%
39Nogami A et al. JAMA 2019≥ 4 weeks≥ 4 weeksNRNR1-2 doses withheld, UFH bridging if > 24 h8 h post procedureWarfarinUninterruptedNR86%84%
40Okishige K et al. J of Card 2017≥ 4 weeks≥ 4 weeksNRNR12-24 h, one dose heldEvening of procedureWarfarinUninterruptedNRNRNR
41Reynolds MR et al. JACC EP 2018≥ 3 weeks≥ 3 weeks2432Uninterrupted Morning of procedureEvening of procedureWarfarinUninterrupted2.3 ± 0.546%69%
42Rilling A et al. JCE 2016NRNR32> 36 hEvening of procedurePhenprocoumonUninterrupted2.3 (2.1,2.5)100%100%
43Snipelisky D et al. J Int Card Electrophys 2012NR≥ 30 daysNRNRMorning of procedureEvening of procedureWarfarinW stopped > 24 hEvening of procedure2-3NRNR
44Snipelisky D et al. J Int Card Electrophys 2014NRNR410R night prior D morning of procedureEvening of procedureWarfarinW stopped > 24 hEvening of procedureNRNRNR
45Somani R et al. Cardiovasc Therap 2014≥ 4 weeks≥ 4 weeksNRNR> 24-30hImmediate post-procedureWarfarinUninterrupted; W stopped 1 week - LMWH until 24-30h prior procedureUninterrupted; LMWH 1/2 dose 4h post hemostasis; 12h full doseNR100%100%
46Stepanyan G et al. J Int Card Electrophys 2014≥ 1 weekNRNRNR> 24-36 hMorning after procedure; UFH infusion 6 h post procedureWarfarinUninterruptedNRPeAF and inconsistent AC last 30 daysPeAF and inconsistent AC last 30 days
47Tang l et al. Frontiers in Med 2020NRNRNRNRMorning of procedureEvening of procedureWarfarinUninterrupted; W stopped 35 days; LMWH bridgeUninterrupted; W night of procedure, LMWH bridgeNR100%100%
48Tao S et al. J Int Card Electroph 2017≥ 4 weeks≥ 4 weeks814UninterruptedUninterruptedWarfarinUninterrupted2.2100%100%
49Tscholl V et al. Clinical Cardio 2017NRNRNRNRMorning of procedureUninterruptedPhenprocoumonUninterrupted1.8 ± 0.5100%100%
50Vlachos K et al. Clinical Cardio 2017≥ 2 monthsNRNRNRUninterrupted R Morning of procedure D, AUninterrupted Evening of procedureAcenocoumarolUninterruptedNR100%100%
51Yamaji H et al. Clin Drug Inv 2013≥ 30 days≥ 30 daysNRNRMorning of procedure3 h post hemostasisWarfarinUninterrupted; W stopped 48 h; UFH subcutaneous bidUninterrupted; ; UFH subcutaneous until INR ≥ 2.02-3100%100%
52Yanagisawa S et al. JACC Clin Electrpph 2018≥ 3 weeks≥ 3 weeks916UninterruptedUninterruptedWarfarinUninterrupted2.0 ± 0.6100%100%
53Yoshimura et al. Journal of Card 2017NRNRNRNRR uninterrupted A morning of procedureEvening of procedureWarfarinUninterrupted2.0 ± 0.6100%100%
DOI: https://doi.org/10.2478/rjc-2025-0018 | Journal eISSN: 2734-6382 | Journal ISSN: 1220-658X
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Language: English
Page range: 104 - 122
Published on: Jun 26, 2025
Published by: Romanian Society of Cardiology
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
atrial fibrillation,
dabigatran,
rivaroxaban,
apixaban,
edoxaban,
DOACS,
NOAC,
warfarin,
Coumadin,
phenprocoumon,
acenocoumarol,
VKA,
vitamin K antagonists,
atrial fibrillation ablation,
pulmonary vein isolation
Related subjects:
Medicine,
Clinical medicine,
Internal medicine,
Cardiology,
Surgery,
Cardiac surgery,
Pediatrics and juvenile medicine,
Paediatric cardiology

© 2025 Dan L Musat, Bogdan Enache, Alexandra Musat, Advay Bhatt, Mohammadali Habibi, Stephanie Kochav, Tina Sichrovsky, Mark W Preminger, Suneet Mittal, published by Romanian Society of Cardiology
This work is licensed under the Creative Commons Attribution 4.0 License.

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