DOACs in AF ablation 43 randomized trial showed no difference between continuous apixaban compared with minimally interrupted apixaban (1 dose withheld) with regard to major bleeding (BARC 3–5) or thromboembolic events (Table 3) (21). Finally, a recent meta-analysis of 4 randomized and 9 prospective observational studies (N = 5463) found that minimally interrupted and continuous NOAC strategy were both safe and non-inferior strategies compared with uninterrupted VKA (14). Our study extends on these results demonstrating less clinically relevant non-major bleeding events with minimally interrupted NOAC in comparison with uninterrupted VKA without compromising thromboembolic safety. One of the reasons to choose an uninterrupted NOAC strategy instead of a minimally interrupted NOAC strategy is to maximally reduce the incidence of thromboembolic events. However, the risk of a systemic thromboembolic event using a minimally interrupted NOAC strategy is already low (<0.7%) (13, 14, 21). Furthermore, continuous anticoagulation does not prevent all acute brain lesions, which can be caused by debris from ablation lesions, air emboli, or small thrombi (22). This was demonstrated by the MRI substudy of the AXAFA trial in which acute brain lesions occurred in 27% of patients despite uninterrupted apixaban (12). Further research is required to establish the optimal NOAC dosing strategy (minimally interrupted or uninterrupted) with regard to both bleeding and thromboembolic risk. Another question is whether every NOAC is effective in preventing periprocedural thromboembolic complications. RCTs with dabigatran (RE-CIRCUIT) and rivaroxaban (VENTUREAF) did not show any thromboembolic events (5, 6), while RCTs with apixaban (AXAFA, AEIOU) showed a low thromboembolic event rate (12, 21). 5. Study limitations There were differences in baseline characteristics between the study groups. The VKA group had a higher proportion of patients with a CHA2DS2-VASc ≥2 in comparison to the NOAC group (47% versus 34%). This difference can be explained by the fact that in patients who did not use an oral anticoagulant (low CHA2DS2-VASc score) and were accepted for catheter ablation, a NOAC was preferentially started as periprocedural anticoagulation regime. This difference in CHA2DS2-VASc score could potentially lower the risk of thromboembolic and bleeding events in the NOAC group. 3
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