Chapter 3 40 NOAC strategy. Patients who did not use oral anticoagulation and were accepted for catheter ablation of AF usually received a NOAC. 2.2 Pre- and periprocedural protocol All patients received therapeutic oral anticoagulation for at least 3 weeks prior to ablation. In patients using VKA the target INR level at the day of the procedure was 2.0 to 2.5. In patients using NOACs, anticoagulation was withheld for 24 h before the procedure (1 or 2 doses withheld). A cardiac CT was routinely performed weeks to months prior to ablation. CT imaging was mainly used to assess PV anatomy. Rarely, a left atrial thrombus could be found as an incidental finding. A preprocedural transoesophageal echocardiogram was routinely performed on the same day or 1 day prior to ablation to exclude left atrial appendage (LAA) thrombus. In the case of LAA thrombus the procedure was cancelled or postponed. During the procedure, a bolus of heparin was administered after sheath placement. Furthermore, immediately after transseptal puncture another bolus of heparin was given and a continuous heparin pump was started and adjusted to maintain an ACT of at least 300 s. We did not administer protamine routinely at the end of the procedure. 2.3 Postprocedural protocol VKA patients, who had an INR 2.0 or greater at the day of the procedure, continued their anticoagulation regimen with a target INR level of 2.0–3.0. VKA patients who had an INR below 2.0 at the day of the procedure were bridged with intravenous UFH for 24 h (starting 2 h after removal of sheaths). After these 24 h they received low molecular weight heparin until their INR level was equal or above 2.0. NOAC patients restarted NOAC in the evening of the procedure. Patients continued their oral anticoagulation for at least 3 months after the procedure. 2.4 Study endpoints Primary bleeding endpoints were major bleeding (within 30 days) as defined by the Bleeding Academic Research Consortium (BARC) and International Society on Thrombosis and Haemostasis (ISTH) (17, 18). The reason to choose both classifications is that clinical trials reporting major bleeding either use ISTH and/or BARC classification. In our study, BARC types 3 to 5 were considered a major bleeding. Secondary bleeding endpoints were the individual BARC bleeding types
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