Summary and general discussion 167 non-major bleeding, major bleeding, and systemic thromboembolic events from the time of ablation through 30 days. Bleeding events were defined by the Bleeding Academic Research Consortium (BARC) and International Society on Thrombosis and Haemostasis (ISTH), as both bleeding scores are commonly used. The rate of clinically relevant non-major bleeding was lower in the DOAC group in comparison to the VKA group. Rates of major bleeding were similar between groups. Rates of systemic embolism were not significantly different, with no events in the minimally interrupted DOAC group, and a few events with uninterrupted VKA. We found that in patients undergoing AF catheter ablation, anticoagulation with minimally interrupted DOAC was associated with fewer clinically relevant non-major bleeding events in comparison with uninterrupted VKA without compromising thromboembolic safety. To improve the outcome of AF ablation, there should not only be a focus on technology. Addressing modifiable risk factors is equally important. A potentially modifiable risk factor for AF is sleep apnea, which shares the same risk factors as AF, such as obesity and hypertension (1, 11, 12). This may be mitigated by lifestyle management such as losing weight and physical exercise. Preferably lifestyle management and treatment of sleep apnea should be initiated before catheter ablation, as it can improve outcome (2). Sleep disordered breathing (SDB) including sleep apnea may hamper the outcome of catheter ablation of AF. Importantly, SDB is not easily recognised and may thus be undertreated. In chapter 4 we evaluated if undiagnosed SDB has an impact on AF recurrence after catheter ablation in a single-center prospective cohort study (13). Patients were enrolled 12 to 18 months after AF catheter ablation. One hundred and four eligible patients were enrolled and underwent SDB screening, using WatchPAT (WP), a portable home sleep apnea test device. We demonstrated that the risk of AF recurrence was significantly higher in the group with undiagnosed SDB in the first year after ablation in comparison to those without SDB. A significant proportion of patients undergoing catheter ablation of AF have undiagnosed SDB which is associated with a twofold higher risk of AF recurrence. SDB screening may improve patient counselling regarding the efficacy of catheter ablation. We found that the commonly used Epworth Sleepiness Scale and STOP-Bang questionnaire underperformed in detecting SDB in our cohort of patients. 10
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