Eventi tromboembolici ed emorragici nei pazienti sottoposti ad ablazione di fibrillazione atriale: confronto a lungo termine dopo sospensione della terapia anticoagulante

ABSTRACT Background. Oral anticoagulation (OAC) is a cornerstone of atrial fibrillation (AF) management, aiming to reduce the risk of stroke and other ischemic events. However, its use is associated with bleeding complications, including hemorrhagic stroke. According to current guidelines, long-term OAC continuation is guided by risk assessment tools such as the CHA₂DS₂-VA score. Rhythm control through catheter ablation has become an increasingly safe and effective strategy to prevent AF recurrence, especially in experienced centers. Recent evidence, including data from the ALONE-AF trial, has explored the potential benefits of discontinuing OAC after successful AF ablation in selected patients. Nevertheless, evidence regarding long-term outcomes following OAC discontinuation remains limited. Aim. To evaluate the long-term incidence of ischemic and hemorrhagic stroke, as well as other systemic thromboembolic events, and bleedings after successful AF ablation in high thromboembolic-risk patients who discontinued OAC therapy (OAC-OFF group) compared with those who continued it (OAC-ON group). Materials and Methods. Patients with a CHA₂DS₂-VA score ≥ 2 who underwent catheter ablation for AF between 2010 and 2024 at Ospedale dell’Angelo, Mestre (VE), were included. Two ablation modalities were considered: radiofrequency and pulsed-field ablation. OAC therapy was discontinued during follow-up in patients without atrial tachyarrhythmia recurrences, based on physician assessment. Clinical data were retrospectively collected from medical records and supplemented with structured telephone interviews. The minimum follow-up duration after ablation was 12 months. Results. A total of 334 patients were included: 108 in the OAC-OFF group and 226 in the OAC-ON group. The mean age was 68.3 years, and approximately 70% were male. After a median follow-up of 4.9 years (4.31 years in the OAC-ON group and 6.41 years in the OAC-OFF group), a total of 19 events were recorded. There was no significant difference between the two groups in the incidence of ischemic thromboembolic events (p = 0.113; HR 0.46, 95% CI 0.18–1.23) or in the overall rate of any type of events (p = 0.096). Hemorrhagic strokes occurred exclusively in the OAC-ON group. Major bleeding was twice as frequent in the OAC-On group, though the difference was not statistically significant (p = 0.314). The composite endpoint of events or death (all-cause) resulted higher in the OAC-On group but at adjusted analysis there was no significant difference. Conclusion. Atrial fibrillation ablation is an effective strategy for achieving rhythm control and may allow safe discontinuation of OAC therapy, even in patients at high ischemic risk, without increasing the incidence of thromboembolic events.