A more specific anticoagulation regimen is required for patients after the Cox-Maze procedure

Background. Long-term management of oral anticoagulation(OAC) after ablation for atrial fibrillation(AF) is an ongoing challenge. Heart Rhythm Society(HRS) guidelines provide no specific recommendationsfor OAC after surgical ablation. The purpose of this studywas to determine the necessity of OAC protocols aftersurgical ablation.

Methods. Patients (N [ 691) who underwent theCox-Maze procedure with left atrial appendage (LAA)management were followed prospectively. All patientswere discharged on OAC unless contraindicated. Cardiacrhythm, bleeding, and embolic stroke or transientischemic attack (TIA), or both, were verified duringfollow-up.

Results. Over a mean follow-up of 47.3 30.3 months,stroke/TIA was reported in 14 patients (5.1 cases per 1,000person-years) and major bleeding events were found in46 patients (16.9 cases per 1,000 person-years). Patientswith major bleeding events had higher median CHADS2(Congestive Heart Failure, Hypertension, Age, Diabetes,Stroke/Transient Ischemic Attack) scores (2 [range, 13]versus 1 [range, 12]; p [ 0.012), but no association wasfound between incidence of stroke/TIA and medianCHADS2 score (1 [range, 02.25] versus 1 [range, 12];p [ 0.377). Patients with CHADS2 scores of 2 or greaterhad the same rates of stroke/TIA (p [ 0.787) but a higherincidence of major bleeding (p [ 0.009) as did patientswith CHADS2 scores less than 2. Adjusting for OACdiscontinuation and stable sinus rhythm, patients withCHADS2 scores of 2 or greater did not have higher stroke/TIA risk (hazard ratio [HR], 0.84; p [ 0.759).

Conclusions. Our results indicate that the decision todiscontinue OAC after the Cox-Maze procedure shouldnot be based solely on CHADS2 scores; rather, rhythmstatus, echocardiographic findings, and patient risk forbleeding should be considered. These findings underscorethe need for an OAC protocol for patients who haveundergone the Cox-Maze procedure with appropriateLAA management.