Chapter 2 26 In non-anticoagulated patients, ECV is associated with an increased risk of stroke (5-7%) (21). This risk is mitigated (<1%) if patients use oral anticoagulation. The 2016 ESC AF guidelines recommends the use of therapeutic oral anticoagulation at least 3 weeks before and 4 weeks after ECV (2). The use of VKA has its limitations, the most important being its narrow therapeutic window requiring regular INR assessments, delayed onset of action and certain drug-drug interactions (11, 22). Considering these limitations, DOACs has become an attractive alternative for VKA (1). In the Netherlands, there was initially a conservative policy with regard to DOAC mainly due to concerns about the lack of an antidote, patient adherence, lack of monitoring and increased health care costs (23). In the Netherlands there was a slower uptake of DOAC use in comparison to other Western European countries (24). Since 2016 there is a steady increase in the use of DOAC in the Netherlands and this is reflected in a higher proportion of patients with DOAC undergoing an elective ECV in our center in the second half of the study period. Nowadays, DOAC is the most commonly used oral anticoagulant pericardioversion. An advantage of the use of DOAC in the setting of ECV is that it can avoid delays or postponement of ECV due to inadequate INR levels with VKA (9, 11). Avoiding postponement and rescheduling of ECV procedures by using DOAC has been shown to be costeffective in comparison to VKA (25). RCTs and meta-analysis have demonstrated the safety and efficacy of DOAC in patients undergoing ECV (7-9, 26-28). Our results are in line with the outcome of the 3 RCTs focusing on pericardioversion DOAC (Appendix C). The mean CHA2DS2VASc score and the proportion of patients with moderate to high thromboembolic risk (CHA2DS2-VASc score ≥2) in our study population was comparable to the RCTs (Appendix C). These randomized trials are important, but the study populations and pre-procedural work-up do not always reflect clinical practice. For example, the EMANATE trial only included anticoagulation naïve patients (<48 hours of anticoagulation before randomization) (8). Furthermore, >50% of patients in the RCTs underwent cardiac imaging to rule out thrombus in the left atrial appendage before ECV. Previous observational studies have shown that in 1.4-3.6% of therapeutically anticoagulated patients a TEE prior to ECV or AF ablation revealed a LAA thrombus (29, 30). The incidence of LAA thrombus seems to correlate with the CHADS-VASc score (29). In many centers, however, preprocedural imaging is not standard practice. Therefore, availability of real-world studies of pericardioversion
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