To the Editor— Perioperative anticoagulation management during thoracoscopic ablation

LETTERS TO THE EDITOR To the Editor— Perioperative anticoagulation management during thoracoscopic ablation With interest we read the article by Romanov et al in the September issue of HeartRhythm.1 They reported that 6 strokes/transient ischemic attacks (TIAs) occurred perioperatively: 4 (4.5%) in patients undergoing thoracoscopic pulmonary vein isolation þ box lesion only and 2 (2.2%) in patients who underwent an additional occlusion of the left atrial appendage (LAA).1 The exact peri- and postoperative anticoagulation protocol was not reported. Compared with other articles on thoracoscopic ablation (TA) or hybrid ablation, the absence of a description of the peri- and postoperative anticoagulation stands out in this article. In our recent report, 1 stroke and 5 asymptomatic thrombi occurred in 17 patients who underwent TA without heparin and without LAA occlusion, but no strokes or asymptomatic thrombi occurred while on heparin and if the LAA was occluded.2 Compared with endocardial catheter ablation, the risk of stroke/TIA seems to be higher during TA; for example, Probst et al 3 reported 5.1% strokes/TIAs. Therefore, one would expect precise reporting of anticoagulation used perioperatively to address this issue. Unfortunately, the opposite seems to be true; clear description of peri- and postoperative anticoagulation management is obviously lacking.1,3 This is in stark contrast to articles on catheter ablation, in which the anticoagulation protocol is described

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in detail. In articles on TA, typically the only anticoagulation information given is with regard to withdrawal of warfarin or novel oral anticoagulants before ablation. Anticoagulation during TA is a difficult task; it could avoid thrombi formation, but it could lead to excessive bleeding. In TA, no standard recommendation for perioperative anticoagulation exists. Most articles on TA are singlecenter studies with limited numbers of patients. Final conclusions on anticoagulation during TA can be drawn only from a meta-analysis of reported trials, and this can happen only if the trials contain the necessary data. We feel it is critical that all future publications on TA include a full description of the exact anticoagulation protocol used. Pavel Osmancik, MD, PhD [email protected] Petr Budera, MD, PhD Cardiocenter, University Hospital Kralovske Vinohrady Charles University, Prague, Czech Republic

References 1. Romanov A, Pokushalov E, Elesin D, et al. Effect of left atrial appendage excision on procedure outcome in patients with persistent atrial fibrillation undergoing surgical ablation. Heart Rhythm 2016;13:1803–1809. 2. Osmancik P, Budera P, Zdarska J, et al. Electrophysiological findings after surgical thoracoscopic atrial fibrillation ablation. Heart Rhythm 2016;13:1246–1252. 3. Probst J, Jidéus L, Blomström P, et al. Thoracoscopic epicardial left atrial ablation in symptomatic patients with atrial fibrillation: Thoracoscopic epicardial left atrial ablation in symptomatic patients with atrial fibrillation. Europace 2016;18: 1538–1544.

http://dx.doi.org/10.1016/j.hrthm.2016.11.028