Heparin Requirements in Patients Undergoing Atrial Fibrillation Ablation on Coumadin vs NOACs

Study Overview
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Brief Summary
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To observe, using a prospectively designed study, the effect of type of oral anticoagulant on intra-procedural heparin requirements in patients undergoing Atrial Fibrillation ablation and to assess whether ACT assay accurately reflects heparin anti coagulation effect.

Detailed Description
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Atrial fibrillation (AF) is the most common arrhythmia affecting the US population and accounts for 15% of strokes worldwide. Radiofrequency ablation has become a frequently used therapy for treatment of afib after failure of at least one anti-arrhythmic drug. Pulmonary Vein Isolation (PVI) remains the cornerstone of AF ablation and requires transseptal puncture and placement of catheters in the left atrium which can be thrombogenic and cause stroke. This is avoided by intra-procedural infusion of heparin and the anti-coagulation effect is monitored using Activated Clotting Time (ACT). With the approval of Novel Oral Anti-Coagulants (NOAC), increasing number of patients are undergoing AF ablation on these medications. It has been observed that patients on NOACs require much larger doses of heparin and take longer time to reach therapeutic ACT. Consequently, patients are at higher risk for thromboembolism and stroke. On the other hand, higher doses of heparin can expose patients to excessive bleeding complications. The investigators seek to explain the mechanism of heparin resistance in such a patient population and to develop a protocol that can achieve therapeutic anticoagulation quicker.

Official Title
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Heparin Requirements in Patients Undergoing Atrial Fibrillation Ablation on Coumadin vs NOACs

Conditions
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Atrial Fibrillation

Intervention / Treatment
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* Diagnostic Test: Monitoring Anti Factor Xa level


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All adults, male and female, aged 18 and above. Patients with paroxysmal, persistent or chronic AF All patients must be on therapeutic doses of Coumadin or one of the NOACs for at least 1 month prior to the procedure. Exclusion Criteria: Patients with known primary or secondary coagulopathy (such as Hemophilia, vWF deficiency, active malignancy, ATIII deficiency, Factor V Leiden deficiency, Hx of recurrent DVT/PE) Patients with hypoalbuminemia, cirrhosis chronic LMWH therapy, ESRD on HD, and severely impaired kidney function with CKD stage IV BMI >35 prosthetic heart valves and advanced liver disease previous procedural complications such as tamponade

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Coumadin<br>Coumadin patients with undergo standard procedure with monitoring of Anti-Factor Xa assay level before and during the procedure. Heparin bolus given will be based on 70 U/kg | Diagnostic Test: Monitoring Anti Factor Xa level<br>* Each patient will have baseline Anti-Factor Xa assay checked. During the procedure, Anti-Factor Xa assay is checked concurrently with ACT after heparin bolus and infusion.<br>|
| Dabigatran<br>Dabigatran patients with undergo standard procedure with monitoring of Anti-Factor Xa assay level before and during the procedure. Heparin bolus given will be based on 110 U/kg | Diagnostic Test: Monitoring Anti Factor Xa level<br>* Each patient will have baseline Anti-Factor Xa assay checked. During the procedure, Anti-Factor Xa assay is checked concurrently with ACT after heparin bolus and infusion.<br>|
| Rivaroxiban<br>Rivaroxiban patients with undergo standard procedure with monitoring of Anti-Factor Xa assay level before and during the procedure. Heparin bolus given will be based on 110 U/kg | Diagnostic Test: Monitoring Anti Factor Xa level<br>* Each patient will have baseline Anti-Factor Xa assay checked. During the procedure, Anti-Factor Xa assay is checked concurrently with ACT after heparin bolus and infusion.<br>|
| Apixaban<br>Apixaban patients with undergo standard procedure with monitoring of Anti-Factor Xa assay level before and during the procedure. Heparin bolus given will be based on 10 U/kg | Diagnostic Test: Monitoring Anti Factor Xa level<br>* Each patient will have baseline Anti-Factor Xa assay checked. During the procedure, Anti-Factor Xa assay is checked concurrently with ACT after heparin bolus and infusion.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Intra-procedural Heparin Requirements in patients taking NOACs and Coumadin | The investigators will measure the amount of intravenous heparin administered to each patient during the afib ablation to achieve therapeutic anticoagulation. | During the procedure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Anti Factor Xa assay measured to assess Heparin activity during Atrial Fibrillation Ablation | The intra-procedural heparin activity is measured using Anti Factor Xa assay. | During the procedure | 
| Activated Clotting Time (ACT) measured to assess Heparin activity during Atrial Fibrillation Ablation | The intra-procedural heparin activity is measured using ACT | During the procedure |