Transesophageal vs. intracardiac echocardiographic screening in patients undergoing atrial fibrillation ablation with uninterrupted rivaroxaban

Background: Patients with atrial fibrillation (AF) routinely undergo different imaging modalities for the evaluation of the left atrial (LA) appendage to rule out thrombus prior to the AF ablation procedure. Recently, uninterrupted novel oral anticoagulants were introduced for patients undergoing atrial fibrillation (AF) ablation to minimize the peri-procedural thromboembolism risk. We performed a retrospective analysis to evaluate the safety of uninterrupted rivaroxaban and whether transesophageal (TEE) or intracardiac echocardiography (ICE) is necessary for patients undergoing AF ablation. Methods: Data from 332 consecutive patients (42% females, aged 64 +/- 11 years) with AF undergoing either TEE (n = 115) prior to catheter ablation or ICE (n = 217) for the detection of LA thrombus were analyzed. All patients were on uninterrupted rivaroxaban during, and for at least, 4 weeks before the procedure. Heparin bolus was administered in all patients before transseptal puncture to maintain a target activated clotting time of >350 s. Results: A total of 277 patients (80.4%) had paroxysmal AF. The average CHA2DS2VASc score was 2.11 +/- 0.91 in the TEE group and 2.46 +/- 0.61 in the ICE group. The CHA2DS2VASc score was >= 2 in 64 (55.7%) and 214 (98.6%) patients in the TEE and ICE groups, respectively. The left atrial appendage was adequately visualized in all cases. None of the patients have an identifiable LA thrombus either in the TEE group or the ICE group. One (0.3%) thromboembolic periprocedural stroke occurred in a patient with long-standing persistent AF in the TEE group. Conclusions: This study illustrates that performing AF ablation with ICE guidance on uninterrupted rivaroxaban for at least 4 weeks even without TEE is feasible and safe.