Safety of pulmonary vein isolation in atrial fibrillation patients treated with dabigatran when idarucizumab is available (RCDD code : vIII)

Patients with atrial fibrillation (AF) are at increased risk of stroke and systemic thromboembolism and prevention of such episodes is ensured by choosing appropriate anticoagulation. In paroxysmal drug‐refractory AF, catheter ablation is the recommended choice of treatment. The decision on whether to stop administration of oral anticoagulant before catheter ablation procedures is often unclear. We present the case of a 67‐year‐old hypertensive woman with a 5‐year history of symptomatic, drug‐refractory paroxysmal AF, who was admitted for pulmonary vein isolation (PVI) and was anticoagulated with dabigatran. After successful transseptal puncture, an intravenous injection of 10 000 units of heparin was administered. Radiofrequency ablation was initiated at the left pulmonary trunk. After the second application of radiofrequency ablation, a drop in arterial blood pressure to 70/50 mmHg was observed. Urgent echocardiography revealed the presence of fluid within the epicardial surface of the left ventricular apex up to 19 mm, behind the right ventricle and right atrium up to 11 mm. Subsequently, all catheters were removed from the left atrium, and 50 mg of protamine sulfate, dopamine, and intravenous fluids were immediately administered. Idarucizumab was urgently delivered to the catheterisation laboratory and was available during patient hospitalisation in the intensive care unit. However, prior to patient discharge, echocardiography revealed only a trace amount of fluid in the pericardium and the use of idarucizumab was not indicated. Interruption of anticoagulation treatment with dabigatran before ablation is not required. Idarucizumab increases the safety of PVI in patients treated with dabigatran. JRCD 2018; 3 (8): 281–283