IMR Press / RCM / Volume 23 / Issue 1 / DOI: 10.31083/j.rcm2301034
Open Access Communication
Periprocedural outcomes of protamine administration after catheter ablation of atrial fibrillation
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1 Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, CA 92354, USA
2 Department of Cardiovascular Medicine, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48309, USA
3 Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
4 Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, KS 66211, USA
*Correspondence: (Jalaj Garg)
Academic Editor: Robert C. Hendel
Rev. Cardiovasc. Med. 2022, 23(1), 34;
Submitted: 2 November 2021 | Revised: 8 December 2021 | Accepted: 8 December 2021 | Published: 19 January 2022
(This article belongs to the Special Issue State-of-the-Art Cardiovascular Medicine in the USA 2022)
Copyright: © 2022 The Author(s). Published by IMR Press.
This is an open access article under the CC BY 4.0 license.

Background: Perioperative anticoagulation management with uninterrupted or minimally interrupted anticoagulation during atrial fibrillation (AF) ablation is thought to be critical to minimize thromboembolic complications. Protamine is often administered to neutralize the effects of heparin and expedite vascular hemostasis post-procedure. Objective: We performed a systematic review and meta-analysis to determine the effectiveness of protamine to expedite vascular hemostasis and ambulation in patients undergoing AF ablation. Methods: Electronic searches on PubMed, The Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases from the inception through August 7, 2021, were performed. The primary outcomes included—time to hemostasis (minutes) and time to ambulation (minutes). The secondary outcomes included - any vascular complications (excluding minor hematoma), minor hematoma, or cerebrovascular accidents (CVA). Results: A total of 5 eligible studies (3 retrospective cohort studies and two randomized trials) consisting of 1012 patients (515 patients received protamine group and 497 patients did not receive protamine group) were included in the meta-analysis. There was a significant reduction in time to ambulation [weighted mean difference (WMD) –176.6 minutes, 95% Confidence interval (CI) –266.9 to –86.3; p < 0.01] and time to hemostasis (WMD –13.72 minutes, 95% CI –22 to –5.4, p < 0.01) in the protamine group compared to the contrary. At a follow-up up to 3 months, there was no statistical difference between the two groups with regards to vascular complications (2.9% vs. 7.4%; Risk ratio (RR) 0.46 95% CI 0.17 to 1.24; p = 0.12), minor hematoma (2.1% vs. 5.8%; RR 0.43, 95% CI 0.16 to 1.2; p = 0.11) or CVA (0 vs. 0.3%; RR 0.62, 95% CI 0.08 to 4.98; p = 0.65). Conclusion: Protamine administration was associated with reduced time to ambulation (176 minutes reduction) and time to hemostasis (13 minutes reduction) without an increase in any adverse events.

Atrial fibrillation ablation
Fig. 1.
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