Chapter 1 10 certain risks associated with electrophysiology procedures. Both ECVs and AF catheter ablation can be associated with the risk of bleeding and thrombo-embolic events (2, 4, 5). For example, AF catheter ablation requires the introduction of catheters in the left atrium. This introduces the risk of air emboli or blood clots resulting in cerebral lesions. Furthermore, vascular access complications and cardiac perforation can occur in patients who are fully anticoagulated. In addition, AF in itself is associated with an elevated risk of ischemic stroke. Preventing the risk of an ischemic stroke usually implies the use of oral anticoagulation, which in turn induces a higher risk of bleeding. In recent years, the use of anticoagulation has shifted from the use of vitamin K anticoagulants (VKAs) to direct oral anticoagulants (DOACs). Several large randomized studies (RE-LY, ROCKET-AF, ARISTOTLE and ENGAGE AF-TIMI) have demonstrated that DOACs have a more favourable risk-benefit profile regarding stroke, intracranial haemorrhage, and mortality (6). Consequently, the use of DOACs has increased considerably over recent years. In the Netherlands there was a slow uptake of its use before 2016, due to limited clinical experience and data on peri-procedural efficacy and safety, lack of an antidote, combined with a lack of reimbursement for patients with AF (7, 8). Since 2016 there was a clear shift from the use of VKA to DOAC in AF patients. This was also observed in the patients who presented for an ECV or AF ablation. In this thesis we evaluated the impact of the increased use of DOACs in our AF population. To improve the outcome of AF ablation, there should not only be a focus on improved technologies. Addressing modifiable risk factors is equally important. A potentially modifiable risk factor for AF is sleep apnoea, and shares the same risk factors, such as overweight and hypertension (1, 9, 10). This may be mitigated by lifestyle management such as losing weight and exercise. Preferably lifestyle management and treatment of sleep apnoea should be initiated before catheter ablation, as it can improve outcome (2). Importantly, sleep apnoea is not easily recognized and may thus be undertreated. In this thesis we evaluated the effect of undiagnosed sleep apnoea on the outcome of AF ablation.
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