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Shah S, Nayfeh T, Hasan B, Urtecho M, Firwana M, Saadi S, Abd-Rabu R, Nanaa A, Flynn DN, Rajjoub NS, Hazem W, Seisa MO, Hassett LC, Spyropoulos AC, Douketis JD, Murad MH. Perioperative Management of Vitamin K Antagonists and Direct Oral Anticoagulants: A Systematic Review and Meta-analysis. Chest 2022; 163:1245-1257. [PMID: 36462533 DOI: 10.1016/j.chest.2022.11.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/30/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The management of patients who are receiving chronic oral anticoagulation therapy and require an elective surgery or an invasive procedure is a common clinical scenario. RESAERCH QUESTION What is the best available evidence to support the development of American College of Chest Physicians guidelines on the perioperative management of patients who are receiving long-term vitamin K agonist (VKA) or direct oral anticoagulant (DOAC) and require elective surgery or procedures? STUDY DESIGH AND METHODS A literature search including multiple databases from database inception through July 16, 2020, was performed. Meta-analyses were conducted when appropriate. RESULTS In patients receiving VKA (warfarin) undergoing elective noncardiac surgery, shorter (< 5 days) VKA interruption is associated with an increased risk of major bleeding. In patients who required VKA interruption, heparin bridging (mostly with low-molecular-weight heparin [LMWH]) was associated with a statistically significant increased risk of major bleed (relative risk [RR], 9.1; 95% CI, 1.62-51.3), representing a very low certainty of evidence (COE). Compared with DOAC interruption 1 to 4 days before surgery, continuing DOACs was not associated with a statistically significant difference in the risk of bleeding, representing a very low COE. Continuing dabigatran was associated with a statistically significant increased risk of thromboembolism (RR, 2.2; 95% CI, 1.3-3.8), representing a low COE. In patients who needed DOAC interruption, bridging with LMWH was associated a with statistically significant increased risk of minor bleeding compared with no bridging (RR, 1.7; 95% CI, 1.13-2.7), representing a low COE. INTERPRETATION The certainty in the evidence supporting the perioperative management of anticoagulants remains limited. No high-quality evidence exists to support the practice of heparin bridging during the interruption of VKA or DOAC therapy for an elective surgery or procedure or for the practice of interrupting VKA therapy for minor procedures, including cardiac device implantation, or continuation of a DOAC vs short-term interruption of a DOAC (1-4 days) in the perioperative period.
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Affiliation(s)
- Sahrish Shah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Tarek Nayfeh
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Meritxell Urtecho
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mohammed Firwana
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Samer Saadi
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rami Abd-Rabu
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Ahmad Nanaa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - David N Flynn
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Noora S Rajjoub
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Walid Hazem
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mohamed O Seisa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Alex C Spyropoulos
- Institute of Health Systems Science-Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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Zheng J, Tu XM, Gao ZY. Successful transcatheter arterial embolization treatment for chest wall haematoma following permanent pacemaker implantation: A case report. World J Clin Cases 2022; 10:11877-11881. [PMID: 36405272 PMCID: PMC9669860 DOI: 10.12998/wjcc.v10.i32.11877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/13/2022] [Accepted: 10/17/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Haematoma is one of the main complications associated with pacemaker implantation. Pseudoaneurysm is a rare condition that is not easy to identify and is often overlooked.
CASE SUMMARY A female patient diagnosed with high-grade atrioventricular block underwent permanent pacemaker implantation. During the operation, puncturing a small branch of the right subclavian artery developed into a pseudoaneurysm and resulted in further haematoma formation. Conventional treatment of compression haemostasis and haemostatic drugs was not effective. A series of timely transcatheter arterial embolizations avoided serious complications.
CONCLUSION More possible conditions should be taken into consideration as haematoma is discovered, and timely treatment might prevent severe adverse events.
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Affiliation(s)
- Jing Zheng
- Department of Cardiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou 324000, Zhejiang Province, China
| | - Xiao-Ming Tu
- Department of Cardiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou 324000, Zhejiang Province, China
| | - Zhen-Yan Gao
- Department of Cardiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou 324000, Zhejiang Province, China
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Wang SX, Bai J, Ma R, Lan RF, Zheng J, Xu W. Fever and neck pain after pacemaker lead extraction: A case report. World J Clin Cases 2019; 7:2103-2109. [PMID: 31423444 PMCID: PMC6695544 DOI: 10.12998/wjcc.v7.i15.2103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/14/2019] [Accepted: 06/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Venous thrombosis (VT) is one of the minor complications of pacemaker lead extraction. It is often found due to the swelling of the limbs after the extraction. It is easy to be neglected or even misdiagnosed in the absence of typical clinical symptoms. The incidence, risk factors, and long-term impact of this complication are still unclear. Herein, we report a case of deep VT caused by transvenous lead extraction, which is easily misdiagnosed.
CASE SUMMARY A 66-year-old woman underwent a pacemaker lead extraction at our hospital because of a pacemaker pocket infection. After the extraction, she began to experience intermittent fever accompanied by sweating. The highest body temperature recorded was 37.9 °C. Additionally, she reported migratory pain that made her uncomfortable. The pain was mistakenly thought to be caused by operation trauma. At first, the pain radiated from the left chest to the mandible. Then, the pain in the left chest was alleviated, but pain in the left neck and throat appeared. Finally, the pain was confined to the mandible and a submandibular mass was palpated with no other abnormalities upon physical examination. Computed tomography venography and angiography finally indicated that the fever and pain were the symptoms of thrombophlebitis caused by lead extraction. The patient was then treated with rivaroxaban for more than three months and has shown no symptoms since she left the hospital.
CONCLUSION The possibility of thrombosis should be considered when pain and recurrent fever occur after pacemaker lead extraction.
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Affiliation(s)
- Shao-Xian Wang
- Department of Cardiology, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, Jiangsu Province, China
| | - Jian Bai
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Rui Ma
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Rong-Fang Lan
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Jia Zheng
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Wei Xu
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
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Stewart MH, Morin DP. Management of Perioperative Anticoagulation for Device Implantation. Card Electrophysiol Clin 2018; 10:99-109. [PMID: 29428146 DOI: 10.1016/j.ccep.2017.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Periprocedural management of anticoagulation for cardiac device implantation has evolved over the past 20 years. The traditional paradigm of vitamin K antagonist interruption with heparin bridging has now been shown to be less safe than continuation of vitamin K antagonists at therapeutic levels. Dual antiplatelet therapy during device implantation poses substantial risk but is often necessary. The safest dosing strategy for newer direct oral anticoagulants is still not clear.
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Affiliation(s)
- Merrill H Stewart
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Daniel P Morin
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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Bleeding risk of submuscular ICD implantation with continued oral anticoagulation versus heparin bridging therapy. Heart Vessels 2017; 33:441-446. [PMID: 29030709 DOI: 10.1007/s00380-017-1064-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
Recent studies have shown that subcutaneous or subfascial pacemaker- and ICD implantation with continued oral anticoagulation therapy is associated with lower risk for bleeding complications, when compared to heparin bridging strategies. However, ICD generators are often implanted submuscularly. We therefore compared the bleeding risk with continued phenprocoumon therapy vs. heparin bridging in patients receiving submuscular ICD implantation. Between 01/2013 and 12/2013, 104 patients with need for oral anticoagulation received submuscular ICD or CRT-D implantation in our institution. 46 patients were implanted under continued phenprocoumon therapy while 58 patients received heparin bridging for implantation procedure. All ICD generators were placed submuscularly. The primary outcome of the study was clinically significant bleeding or device pocket hematoma with need for surgical revision. Mean patients age was 63.7 years, 72.1% were male. In patients with heparin bridging therapy, preoperative INR prior to ICD implantation was 1.2 ± 0.31 while in the group of patients on continued phenprocoumon therapy, mean pre-OP INR was 2.4 ± 0.47. In heparin bridging group, 8 (13.8%) patients experienced a clinically relevant pocket hematoma, while only 1 (2.2%) patient on continued phenprocoumon therapy needed surgical revision for pocket hematoma (P = 0.04). No further bleeding complications or clinically relevant pericardial effusion was observed in any of the groups and no perioperative thromboembolic event occurred. Submuscular ICD implantation under continued phenprocoumon therapy was safe and feasible. Compared to patients with heparin bridging therapy, those with continued phenprocoumon therapy had a lower incidence of clinically relevant bleeding complications.
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He H, Ke BB, Li Y, Han FS, Li X, Zeng YJ. Perioperative management of antithrombotic therapy in patients receiving cardiovascular implantable electronic devices: a network meta-analysis. J Interv Card Electrophysiol 2017; 50:65-83. [PMID: 28842832 DOI: 10.1007/s10840-017-0280-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/10/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Network meta-analysis (NMA) has advantages including being able to simultaneously compare and rank multiple treatments over traditional meta-analysis. We evaluated by a NMA the optimal antithrombotic strategy during the perioperative period of implantation of cardiovascular implantable electronic devices (CIEDs). METHODS We performed a network meta-analysis of observational studies (cohort and case-control studies). The eligible studies tested the following antithrombotic therapy during the CIED placement: aspirin, clopidogrel, warfarin, novel oral anticoagulants (NOACs), and heparin bridging. RESULTS Thirty-one observational studies with 119 study arms were included (41,174 patients receiving long-term antithrombotic therapy; median age, 72.6 years; 70.1% males; median follow-up, 3.6 years). Aspirin (4.26 [2.88-7.22]), warfarin (3.37 [2.17-5.23]), and clopidogrel (3.30 [1.49-5.88]) reduced the risk of bleeding as compared with heparin bridging, and there was no significance difference between continued NOACs and heparin bridging (0.67 [0.21-2.18]). The comparison of commonly used protocols in the management of anticoagulant therapy revealed that continued warfarin (0.38 [0.20-0.74]), continued NOACs (0.19 [0.04-0.89]), and heparin bridging therapy (0.01 [0.05-0.21]) increased the risk of bleeding as compared that of control, and continued warfarin (3.74 [1.96-7.16]), interrupted warfarin (4.89 [2.20-10.88]), and interrupted NOACs (12.5 [1.25-100]) reduced the risk of bleeding compared with that of heparin bridging. CONCLUSIONS Among various antithrombotic drugs, aspirin had the lowest bleeding risk, followed by warfarin, clopidogrel and NOACs, and heparin, with the greatest bleeding risk. NOACs therapy appears safe and effective, and interrupted NOACs may be the optimal anticoagulation protocol for use during the perioperative period of CIED implantation.
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Affiliation(s)
- Hua He
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China.
| | - Bing-Bing Ke
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yan Li
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, 100029, China
| | - Fu-Sheng Han
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Xiaodong Li
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yu-Jie Zeng
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
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Koh Y, Bingham NE, Law N, Le D, Mariani JA. Cardiac implantable electronic device hematomas: Risk factors and effect of prophylactic pressure bandaging. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:857-867. [PMID: 28543543 DOI: 10.1111/pace.13106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/14/2017] [Accepted: 04/24/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cardiac implantable electronic device (CIED) hematomas are associated with many adverse outcomes. We examined the incidence and risk factors associated with hematoma formation post-CIED implantation, and explored the preventative effect of prophylactic pressure bandaging (PPB) in a large tertiary center. METHODS 1,091 devices were implanted during October 2011-December 2014. Clinically significant hematomas (CSH) were those that necessitated prolonged admission, including those due to reoperation, and clinically suspicious hematomas were swellings noted by medical/nursing staff. We screened for variables affecting hematoma incidence prior to conducting multivariate logistic regression analyses, one for all hematomas and one for CSH. RESULTS 61 hematomas were identified (5.6% of patients), with 12 of those clinically significant (1.1% of patients). Factors significantly increasing the odds of developing any hematoma were stage 2 (odds ratio [OR] = 2.93, 95% confidence interval [CI] [1.08-7.94], P = 0.034) and 3 chronic kidney disease (CKD) (OR = 3.39 [1.20-9.56], P = 0.021), unfractionated heparin/therapeutic enoxaparin (OR = 3.15 [1.22-8.14], P = 0.018), and dual antiplatelets-aspirin + clopidogrel (OR = 2.95 [1.14-7.65], P = 0.026) + other combinations. Body Mass index (BMI) 25.0-29.9 (OR 0.52 [0.28-0.98], P = 0.044) and >30 were associated with decreased hematoma risk (OR 0.43 [0.20-0.91], P = 0.028). Factors significant for CSH formation were unfractionated heparin/therapeutic enoxaparin (OR = 9.55 [1.83-49.84], P = 0.007) and aspirin + clopidogrel (OR = 7.19 [1.01-50.91], P = 0.048). PPB nonsignificantly increased the odds of total hematoma development (OR = 1.53 [0.87-2.69], P = 0.135), and reduced CSH (OR = 0.67 [0.18-2.47], P = 0.547). CONCLUSIONS Heparin and dual antiplatelet use remain strong predictors of overall hematoma formation. CKD is a comparatively moderate predictor. BMI > 25 may decrease the risk of hematoma formation. PPB had nonsignificant effects on hematoma development.
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Affiliation(s)
- Youlin Koh
- Department of Cardiology, The Alfred Hospital, Prahran, Victoria, Australia
| | - Nicholas E Bingham
- Department of Cardiology, The Alfred Hospital, Prahran, Victoria, Australia
| | - Natalie Law
- Monash University, Clayton, Victoria, Australia
| | - Dustin Le
- Monash University, Clayton, Victoria, Australia
| | - Justin A Mariani
- Department of Cardiology, The Alfred Hospital, Prahran, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Prahran, Victoria, Australia, 3004
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Terekhov D, Agapov V, Kulikov K, Zadorozhnaya S, Samitin V, Maslyakov V. Pacemaker Implantation in Elderly Patients: Safety of Various Regimens of Anticoagulant Therapy. J Atr Fibrillation 2017; 9:1467. [PMID: 29250265 PMCID: PMC5673381 DOI: 10.4022/jafib.1467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 08/19/2016] [Accepted: 01/14/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To study incidence of hemorrhagic complications after pacemaker implantation in elderly patients receiving antithrombotic therapy with warfarin or uninterrupted dabigatran. METHODS 126 patients aged 83 [82; 85] years who receive continuous antithrombotic therapy after pacemaker implantation, were enrolled in the study. Adverse event data were collected during hospitalization and further 12 weeks. RESULTS 95 subjects (75.4%) from general number of enrolled patients received elective anticoagulant warfarin therapy and 31 subjects (24.6%) were treated with dabigatran. All patients of dabigatran group received 220 mg/day skipping the last dose before a surgery and resumed the drug intake in 36-48 hours after it. Patients of warfarin group underwent surgery if INR was NMT 3; they didn't stop taking the drug for the duration of operation.No statistically significant differences of hematoma incidence were detected in dabigatran (incidence is 0.065, 95%CI (-0.02-0.15)) and warfarin (incidence is 0.05, 95%CI (0.006-0.01)) groups, p(Fisher)= 0.55. Three cases of nonfatal gastrointestinal bleeding (warfarin group) and 1 similar event in dabigatran group were detected during a follow-up (12 [6; 20] weeks): RR= 0.98 (warfarin group), p(Fisher)=0.68. No statistically significant difference of age, sex composition, history of IHD and diabetes was detected between groups by comparison of individual characteristics of patients whose surgeries were complicated/non-complicated by hematoma formation. Upon that, hematoma formation rate was significantly higher in patients with adjunctive pacemaker muscular fixation: 71.4% vs 31.9% (patients without hematomas), p(Fisher)= 0.045. CONCLUSION Incidence of hematoma formation after pacemaker implantation in patients > 75 years receiving warfarin or dabigatran, is the same as in general population of patients treated with anticoagulants. Adjunctive pacemaker muscular fixation is a significant risk factor of hematoma formation.
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Affiliation(s)
- Denis Terekhov
- Saratov Regional Cardiac Centre; Krymskaya ulitsa, 15, Saratov, 410039, Russian Federation
| | - Valeriy Agapov
- Saratov Regional Cardiac Centre; Krymskaya ulitsa, 15, Saratov, 410039, Russian Federation
| | - Kirill Kulikov
- Saratov Regional Cardiac Centre; Krymskaya ulitsa, 15, Saratov, 410039, Russian Federation
| | - Svetlana Zadorozhnaya
- Saratov Regional Cardiac Centre; Krymskaya ulitsa, 15, Saratov, 410039, Russian Federation
| | - Vasiliy Samitin
- Saratov Regional Cardiac Centre; Krymskaya ulitsa, 15, Saratov, 410039, Russian Federation
| | - Vladimir Maslyakov
- Saratov Medical Institute “REAVIZ”; ulitsa Verkhny Rynok, 10, Saratov, 410004, Russian Federation
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Madan S, Muthusamy P, Mowers KL, Elmouchi DA, Finta B, Gauri AJ, Woelfel AK, Fritz TD, Davis AT, Chalfoun NT. Safety of anticoagulation with uninterrupted warfarin vs. interrupted dabigatran in patients requiring an implantable cardiac device. Cardiovasc Diagn Ther 2016; 6:3-9. [PMID: 26885486 DOI: 10.3978/j.issn.2223-3652.2015.10.06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The optimal strategy of peri-procedural anticoagulation in patients undergoing permanent cardiac device implantation is controversial. Our objective was to compare the major bleeding and thromboembolic complications in patients managed with uninterrupted warfarin (UW) vs. interrupted dabigatran (ID) during permanent pacemaker (PPM) or implantable cardioverter defibrillators (ICD) implantation. METHODS A retrospective cohort study of all eligible patients from July 2011 through January 2012 was performed. UW was defined as patients who had maintained a therapeutic international normalized ratio (INR) on the day of the procedure. ID was defined as stopping dabigatran ≥12 hours prior to the procedure and then resuming after implantation. Major bleeding events included hemothorax, hemopericardium, intracranial hemorrhage, gastrointestinal bleed, epistaxis, or pocket hematoma requiring surgical intervention. Thromboembolic complications included stroke, transient ischemic attack, deep venous thrombosis, pulmonary embolism, or arterial embolism. RESULTS Of the 133 patients (73.4±11.0 years; 91 males) in the study, 86 received UW and 47 received ID. One (1.2%) patient in the UW group sustained hemopericardium perioperatively and died. In comparison, the ID patients had no complications. As compared to the ID group, the UW group had a higher median CHADS2 score (2 vs. 3, P=0.04) and incidence of Grade 1 pocket hematoma (0% vs. 7%, P=0.09). Neither group developed any thromboembolic complications. CONCLUSIONS Major bleeding rates were similar among UW and ID groups. Perioperative ID appears to be a safe anticoagulation strategy for patients undergoing PPM or ICD implantation.
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Affiliation(s)
- Shivanshu Madan
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Purushothaman Muthusamy
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Katie L Mowers
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Darryl A Elmouchi
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Bohuslav Finta
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Andre J Gauri
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Alan K Woelfel
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Timothy D Fritz
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Alan T Davis
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
| | - Nagib T Chalfoun
- 1 University of North Carolina Hospitals, Chapel Hill, NC, USA ; 2 St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA, USA ; 3 St. Louis Children's Hospital, Washington University, St. Louis, MO, USA ; 4 Spectrum Health, Department of Cardiovascular Services, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI, USA ; 5 Department of Research, Grand Rapids Medical Education Partners, Grand Rapids, MI, USA ; 6 Department of Surgery, Michigan State University, USA
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10
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Lip GY, Windecker S, Huber K, Kirchhof P, Marin F, Ten Berg JM, Haeusler KG, Boriani G, Capodanno D, Gilard M, Zeymer U, Lane D, Storey RF, Bueno H, Collet JP, Fauchier L, Halvorsen S, Lettino M, Morais J, Mueller C, Potpara TS, Rasmussen LH, Rubboli A, Tamargo J, Valgimigli M, Zamorano JL. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J 2014; 35:3155-79. [DOI: 10.1093/eurheartj/ehu298] [Citation(s) in RCA: 432] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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11
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Abstract
For patients prescribed chronic vitamin K antagonist therapy requiring a surgical or invasive procedure, the question of whether or not to bridge and how to bridge is commonly encountered in clinical practice. Bridging anticoagulation has evolved over the years and the evidence base for current practice is deficient in many areas. Clinical trials currently being completed with conventional anticoagulants should help strengthen the evidence base for future practice. The availability of novel oral anticoagulants is a welcome addition, though their optimal management peri-procedure is yet to be determined. Prospective multi-centre controlled studies that can provide the evidence base for novel oral anticoagulant peri-procedural management are required.
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Affiliation(s)
- Jignesh P Patel
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, UK; Institute of Pharmaceutical Science, King's College London, London, UK
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12
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Özcan KS, Osmonov D, Yıldırım E, Altay S, Türkkan C, Ekmekçi A, Güngör B, Erdinler İ. Hematoma complicating permanent pacemaker implantation: The role of periprocedural antiplatelet or anticoagulant therapy. J Cardiol 2013; 62:127-30. [DOI: 10.1016/j.jjcc.2013.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 03/06/2013] [Accepted: 03/08/2013] [Indexed: 11/26/2022]
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13
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BAROLD SS, GIUDICI MICHAEL, HERWEG BENGT. Uninterrupted Warfarin Therapy for the Implantation of Cardiac Rhythm Devices. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:537-40. [DOI: 10.1111/pace.12096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 11/19/2012] [Accepted: 12/26/2012] [Indexed: 12/01/2022]
Affiliation(s)
- S. S. BAROLD
- Florida Heart Rhythm Institute; Tampa General Hospital; Tampa; Florida
| | - MICHAEL GIUDICI
- Division of Cardiology; University of Iowa Hospitals; Iowa City; Iowa
| | - BENGT HERWEG
- Florida Heart Rhythm Institute; Tampa General Hospital; Tampa; Florida
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14
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Tratamiento perioperatorio del paciente con antiagregación o anticoagulación. REVISTA COLOMBIANA DE CARDIOLOGÍA 2012. [DOI: 10.1016/s0120-5633(12)70141-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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15
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Mangrolia N, Nayar V, Pugh PJ. Managing anticoagulation in patients receiving implantable cardiac devices. Future Cardiol 2012. [PMID: 26203472 DOI: 10.2217/fca.11.88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
A substantial proportion of patients who undergo cardiac rhythm device implantation receive anticoagulation to prevent thromboembolism. Many patients have coexisting cardiovascular diseases treated with antiplatelet therapy. Anticoagulation may increase the risk of hemorrhagic complication, while withdrawal of anticoagulation may increase thromboembolic risk. In this article, we review and describe the available evidence, in order to inform best practice .
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Affiliation(s)
- Neil Mangrolia
- Box 263, Ward K2, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
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16
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Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S-e350S. [PMID: 22315266 DOI: 10.1378/chest.11-2298] [Citation(s) in RCA: 1043] [Impact Index Per Article: 86.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. METHODS The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement. RESULTS In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C). CONCLUSIONS Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Michael Mayr
- Medical Outpatient Department, University Hospital Basel, Basel, Switzerland
| | - Amir K Jaffer
- Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati Medical Center, Cincinnati, OH
| | - Andrew S Dunn
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Regina Kunz
- Academy of Swiss Insurance Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland.
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17
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Brinker J. Device surgery in the anticoagulated patient: The Goldilocks principle. Heart Rhythm 2012; 9:368-9. [DOI: 10.1016/j.hrthm.2011.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Indexed: 11/24/2022]
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18
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Kossaify A. Conservative Management of Skin Fistula Occurring after Internal Cardioverter Defibrillator Replacement. CLINICAL MEDICINE INSIGHTS: CASE REPORTS 2012; 5:9-12. [PMID: 22399867 PMCID: PMC3290119 DOI: 10.4137/ccrep.s8974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Skin fistula occurring after cardiac electronic device implantation is frequently related to pocket infection and this condition typically requires removal of device and lead(s). We report on a case of skin fistula occurring 3 weeks after internal cardioverter defibrillator replacement. Conservative management consisted of local care along with oral antibiotics without removal of device; this strategy resulted in complete healing and closure of the fistula.
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Affiliation(s)
- Antoine Kossaify
- USEK-NDS University Hospital, Cardiology Division, Electrophysiology Unit, Byblos, Lebanon
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19
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Korantzopoulos P, Letsas KP, Liu T, Fragakis N, Efremidis M, Goudevenos JA. Anticoagulation and antiplatelet therapy in implantation of electrophysiological devices. Europace 2011; 13:1669-1680. [PMID: 21788280 DOI: 10.1093/europace/eur210] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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