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Deer TR, Russo MA, Sayed D, Pope JE, Grider JS, Hagedorn JM, Falowski SM, Al-Kaisy A, Slavin KV, Li S, Poree LR, Eldabe S, Meier K, Lamer TJ, Pilitsis JG, De Andrés J, Perruchoud C, Carayannopoulos AG, Moeschler SM, Hadanny A, Lee E, Varshney VP, Desai MJ, Pahapill P, Osborn J, Bojanic S, Antony A, Piedimonte F, Hayek SM, Levy RM. The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for the Mitigation of Complications of Neurostimulation. Neuromodulation 2024; 27:977-1007. [PMID: 38878054 DOI: 10.1016/j.neurom.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION The International Neuromodulation Society convened a multispecialty group of physicians based on expertise and international representation to establish evidence-based guidance on the mitigation of neuromodulation complications. This Neurostimulation Appropriateness Consensus Committee (NACC)® project intends to update evidence-based guidance and offer expert opinion that will improve efficacy and safety. MATERIALS AND METHODS Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to October 2023. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant. RESULTS The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS The NACC recommends best practices regarding the mitigation of complications associated with neurostimulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA.
| | | | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Adnan Al-Kaisy
- Guy's and St. Thomas National Health Service (NHS) Foundation Trust, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA; Neurology Section, Jesse Brown Veterans Administration Medical Center, Chicago, IL, USA
| | - Sean Li
- National Spine & Pain Centers, Shrewsbury, NJ, USA
| | - Lawrence R Poree
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - Sam Eldabe
- The James Cook University Hospital, Middlesbrough, UK
| | - Kaare Meier
- Department of Anesthesiology (OPINord), Aarhus University Hospital, Aarhus, Arhus, Denmark; Department of Neurosurgery (Afd. NK), Aarhus University Hospital, Aarhus, Arhus, Denmark
| | | | | | - Jose De Andrés
- Valencia School of Medicine, Anesthesia Critical Care and Pain Management Department, General University Hospital, Valencia, Spain
| | | | - Alexios G Carayannopoulos
- Department of Physical Medicine and Rehabilitation and Comprehensive Spine Center, Rhode Island Hospital, Providence, RI, USA; Brown University Warren Alpert Medical School (Neurosurgery), Providence, RI, USA
| | - Susan M Moeschler
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amir Hadanny
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Eric Lee
- Mililani Pain Center, Mililani, HI, USA
| | - Vishal P Varshney
- Anesthesiology and Pain Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Mehul J Desai
- International Spine, Pain & Performance Center, Virginia Hospital Center, Monument Research Institute, George Washington University School of Medicine, Arlington, VA, USA
| | - Peter Pahapill
- Functional Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Osborn
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Stana Bojanic
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ajay Antony
- The Orthopaedic Institute, Gainesville, FL, USA
| | - Fabian Piedimonte
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Franczyk B, Rysz J, Olszewski R, Gluba-Sagr A. Do Implantable Cardioverter-Defibrillators Prevent Sudden Cardiac Death in End-Stage Renal Disease Patients on Dialysis? J Clin Med 2024; 13:1176. [PMID: 38398488 PMCID: PMC10889557 DOI: 10.3390/jcm13041176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/23/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Chronic kidney disease patients appear to be predisposed to heart rhythm disorders, including atrial fibrillation/atrial flutter, ventricular arrhythmias, and supraventricular tachycardias, which increase the risk of sudden cardiac death. The pathophysiological factors underlying arrhythmia and sudden cardiac death in patients with end-stage renal disease are unique and include timing and frequency of dialysis and dialysate composition, vulnerable myocardium, and acute proarrhythmic factors triggering asystole. The high incidence of sudden cardiac deaths suggests that this population could benefit from implantable cardioverter-defibrillator therapy. The introduction of implantable cardioverter-defibrillators significantly decreased the rate of all-cause mortality; however, the benefits of this therapy among patients with chronic kidney disease remain controversial since the studies provide conflicting results. Electrolyte imbalances in haemodialysis patients may result in ineffective shock therapy or the appearance of non-shockable underlying arrhythmic sudden cardiac death. Moreover, the implantation of such devices is associated with a risk of infections and central venous stenosis. Therefore, in the population of patients with heart failure and severe renal impairment, periprocedural risk and life expectancy must be considered when deciding on potential device implantation. Harmonised management of rhythm disorders and renal disease can potentially minimise risks and improve patients' outcomes and prognosis.
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Affiliation(s)
- Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Lodz, Poland; (B.F.); (J.R.)
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Lodz, Poland; (B.F.); (J.R.)
| | - Robert Olszewski
- Department of Gerontology, Public Health and Didactics, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Anna Gluba-Sagr
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-419 Lodz, Poland; (B.F.); (J.R.)
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 213] [Impact Index Per Article: 213.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Kartsouni V, Moschouris H, Bersimis F, Gkeneralis G, Gkeli M, Dodoura S, Chouchourelou A, Fezoulidis I, Kotsakis A, Rountas C. Complications of Totally Implantable Central Venous Catheters (Ports) Inserted via the Internal Jugular Vein Under Ultrasound and Fluoroscopy Guidance in Adult Oncology Patients: A Single-Center Experience. Cureus 2022; 14:e27485. [PMID: 36060391 PMCID: PMC9421351 DOI: 10.7759/cureus.27485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 01/17/2023] Open
Abstract
Introduction In this retrospective study, the safety and complication rates of port implantations via the internal jugular vein under ultrasound and fluoroscopy guidance in adult oncology patients were analyzed. Material and methods Eight hundred seven ports implanted in 799 adult oncology patients at a tertiary Oncology-Anticancer Hospital during a 36-month period from January 1, 2017 to December 31, 2019 were retrospectively reviewed. Data acquisition was obtained until December 31, 2020. All procedures were performed by two specialized interventional radiologists under ultrasound and fluoroscopy guidance. The vein access was via the internal jugular vein. Catheter days (the total number of days of maintenance of the port by all of the patients until removal, death, or December 31, 2020), technical success rates, and complication rates were evaluated based on the interventional radiological reports and patient medical records. Multivariate analysis regarding patients such as age, sex, body mass index (BMI), marital status, educational level, cancer type, side of insertion, diameter of internal jugular vein, diabetes, anticoagulants/antiplatelets, purpose of implantation, and catheter material as to the risk of complications was conducted. Results A total of 369,329 catheter maintenance days were observed (457.7±345.0). The technical success rate was 99.9%, and a total of 85 (10.5%) complications occurred, of which 24 (28.2%) occurred early (<30 days) and the remaining 61 (71.8%) were late (>30 days) complications. Specifically, 28 (3.5%) were catheter-related thrombosis (CRT), 27 (3.4%) related to infection, 17 (2.1%) were mechanical complications (16 fibrin sheath formation and one catheter occlusion), six (0.7%) related to catheter migration, four (0.5%) related to incision healing problems, and the remaining three (0.4%) related to ischemic skin necrosis. Forty-seven (5.8%) ports were removed due to complications. On multivariate analysis, cancer type was found as a risk factor for the development of a complication. Additionally, there was an indication that hematologic malignancy is related to infection. Conclusion Placement of ports via the internal jugular vein under ultrasound and fluoroscopy guidance is a safe procedure, with low rates of early and late complications.
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Impact on All-Cause and Cardiovascular Mortality of Cardiac Implantable Electronic Device Complications. JACC Clin Electrophysiol 2020; 6:382-392. [PMID: 32327071 DOI: 10.1016/j.jacep.2019.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 11/18/2022]
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Song J, Tark A, Larson EL. The relationship between pocket hematoma and risk of wound infection among patients with a cardiovascular implantable electronic device: An integrative review. Heart Lung 2020; 49:92-98. [DOI: 10.1016/j.hrtlng.2019.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/05/2019] [Accepted: 09/25/2019] [Indexed: 01/31/2023]
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Management of anticoagulation in patients undergoing leadless pacemaker implantation. Heart Rhythm 2019; 16:1849-1854. [DOI: 10.1016/j.hrthm.2019.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Indexed: 11/20/2022]
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Graham AJ, Providenica R, Honarbakhsh S, Srinivasan N, Sawhney V, Hunter R, Lambiase P. Systematic review and meta-analysis of left ventricular endocardial pacing in advanced heart failure: Clinically efficacious but at what cost? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:353-361. [PMID: 29344950 DOI: 10.1111/pace.13275] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 12/04/2017] [Accepted: 12/22/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Cardiac resynchronization using a left ventricular (LV) epicardial lead placed in the coronary sinus is now routinely used in the management of heart failure patients. LV endocardial pacing is an alternative when this is not feasible, with outcomes data sparse. OBJECTIVE To review the available evidence on the efficacy and safety of endocardial LV pacing via meta-analysis. METHODS EMBASE, MEDLINE, and COCHRANE databases with the search term "endocardial biventricular pacing" or "endocardial cardiac resynchronization" or "left ventricular endocardial" or "endocardial left ventricular." Comparisons of pre-and post-QRS width, LV ejection fraction (LVEF), and New York Heart Association (NYHA) functional classification was performed, and mean differences (and respective 95% confidence interval [CI]) applied as a measurement of treatment effect. RESULTS Fifteen studies, including 362 patients, were selected. During a mean follow-up of 40 ± 24.5 months, death occurred in 72 patients (11 per 100 patient-years). Significant improvements in LVEF (mean difference 7.9%, 95% CI 5-10%, P < 0.0001; I2 = 73%), QRS width (mean difference: -41% 95% -75 to -7%; P < 0.0001; I2 = 94%), and NYHA class (mean difference: -1.06, 95% CI -1.2 to -0.9, P < 0.0001; I2 = 60%), (all P < 0.0001) occurred. Stroke rate was 3.3-4.2 per 100 patient-years, which is higher than equivalent heart failure trial populations and recent meta-analysis that included small case series. CONCLUSION LV endocardial lead implantation is a potentially efficacious alternative to CS lead placement, but preliminary data suggest a potentially higher risk of stroke during follow-up when compared to the expected incidence of stroke in similar cohorts of patients.
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Affiliation(s)
- Adam J Graham
- Clinical Research Fellow, Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Rui Providenica
- Clinical Research Fellow, Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Shohreh Honarbakhsh
- Clinical Research Fellow, Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Neil Srinivasan
- Clinical Research Fellow, Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Vinit Sawhney
- Clinical Research Fellow, Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Ross Hunter
- Consultant Electrophysiologist and Clinical lecturer, Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
| | - Pier Lambiase
- Consultant Electrophysiologist and Clinical lecturer, Barts Heart Centre, West Smithfield, London, EC1A 7BE, UK
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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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Feng L, Li Y, Li J, Yu B. Oral anticoagulation continuation compared with heparin bridging therapy among high risk patients undergoing implantation of cardiac rhythm devices. Thromb Haemost 2017; 108:1124-31. [DOI: 10.1160/th12-07-0498] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 09/16/2012] [Indexed: 01/29/2023]
Abstract
SummaryIt was the objective of this study to systematically compare the effects of oral anticoagulation (OAC) with heparin bridging therapy among patients at high risk for thromboembolism undergoing implantation of cardiac rhythm devices. A systematic search of PubMed/MEDLINE, Ovid and Elsevier, and the Cochrane Library databases was conducted. Six trials that met our inclusion criteria were identified and included in the present study. The endpoints of this meta-analysis included pocket haematoma, severe haematoma requiring drainage/revision, thromboembolic events, and length of hospital stay. Data were expressed as odds ratios (ORs) and 95% confidence interval (CIs). There was a statistically significant reduction of pocket haematoma (OR 0.29, 95% CI: 0.17 to 0.49, p<0.00001) and haematoma drainage/revision (OR 0.15, 95%CI: 0.04 to 0.54, p=0.004), respectively, in the OAC continuation group versus the heparin bridging group. We did not detect any statistically sig- nificant differences of thromboembolic events (OR 0.48, 95%CI: 0.07 to 3.54, p=0.48) in the two groups. There was a trend that patients in bridging group had longer hospital stays. In conclusion, OAC continu- ation had a better risk-beneficial ratio and shorter length of hospital stay, and was more convenient to implement compared with heparin bridging therapy among patients at high risk for thromboembolism undergoing implantation of cardiac rhythm devices.
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Prospective randomized study evaluating the effects of PerClot® (Polysaccharide Hemostatic System) application in patients with high bleeding risk undergoing cardiac rhythm device implantation. Int J Cardiol 2017; 248:84-91. [PMID: 28843718 DOI: 10.1016/j.ijcard.2017.08.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/24/2017] [Accepted: 08/14/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Thus far, the topic hemostatic agent PerClot® is used for surgical procedures. Data about the use of PerClot® for cardiac-rhythm-devices (CRD) implantation are missing. The aim of this study was to evaluate the safety and efficacy of PerClot® in patients with high bleeding risk. METHODS AND RESULTS In this prospective randomized study we planned to include 150 patients admitted for CRD-Implantation receiving anticoagulation and/or dual-antiplatelet-therapy. Participants were randomized to receive PerClot® versus standard-of-care. The primary endpoint was the incidence of pocket hematoma. Safety endpoint was pocket infection. After a planned safety-interim-analysis the study was terminated early because of safety concerns. 51 patients were included. The two groups were comparable with regard to age (73±11years vs. 74±10years; p=0.71), CHA2DS2VASc (3.6±1.5 vs. 4.0±1.5; p=0.27) and HASBLED-Score (2.4±1.1 vs. 2.5±1.0; p=0.98), CRD or procedure type, anticoagulant or anti-platelet therapy. The use of PerClot® resulted in a higher incidence of postoperative fever (7 (28%) vs. 0 (0%); p=0.004), higher C-Reactive Protein (66.1±50.5mg/l vs. 25.9±22.5mg/l; p=0.002); and higher postoperative white blood cell count (13.5±4.3/nl vs. 8.8±2.6/nl; p<0.001). Hematoma formation did not differ significantly (p=0.14). Reoperation was not necessary in any patient. CONCLUSION This first randomized controlled study for the topical use of the hemostatic agent PerClot® in CRD implantation was terminated early by the safety monitoring board because of an augmented rate of fever and inflammatory markers in the PerClot® group. The addition of PerClot® does not suggest a benefit with regard to the frequency of pocket hematoma.
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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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[Safety of device implantation under antipatelet therapy with ticagrelor: About 20 cases]. Ann Cardiol Angeiol (Paris) 2016; 65:318-321. [PMID: 27693167 DOI: 10.1016/j.ancard.2016.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/02/2016] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Management of antiplatelet therapy at the time of device implantation remains controversial. This study aimed to assess the risk of bleeding complications in patients receiving ticagrelor at the time of cardiac device surgery. METHODS We performed a multicentre (n=4), retrospective study from January 2015 to January 2016. The survey included all patients (pts) treated with ticagrelor before undergoing pacemaker, implantable cardioverter-defibrillator (ICD) implantation or generator replacement. We report hemorrhagic post-procedural complications at 1 month. A significant bleeding complication was defined as pocket hematoma requiring a surgical evacuation or prolonged hospitalization, hemothorax, pericardial effusion, or tamponade. RESULTS A total of 20 patients underwent a permanent pacemaker or ICD implantation while taking a combination of antipatelet therapy with ticagrelor and aspirin. The mean age of the patients was 65±9 years, 95% were male, 25% of patients were diabetics, 55% had hypertension and 50% presented a history of heart failure. All the patients had a history of acute coronary syndrome [6 (4-26) months before the procedure]. The majority of implanted devices were ICDs (17, 85%) with 5 single chamber, 4 dual chambers and 9 triple chambers ICDs. Subclavian venous approach was utilized in 9 patients. The mean duration of procedure was 60minutes. One per-procedure bleeding was described due to high venous pressure, without post-procedure hematoma. A post-procedure pocket hematoma has been experienced by one patient. The subclavian approach was used for the 2 patients. No blood transfusion was needed for these 2 cases. CONCLUSION Ticagrelor treatment at the time of heart rhythm device procedures does not seem to be associated with an increased risk of significant bleeding complications. In our study, 2 patients experienced nonsignificant bleeding complications.
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Dunn AS, Wisnivesky J, Ho W, Moore C, McGinn T, Sacks HS. Perioperative Management of Patients on Oral Anticoagulants: A Decision Analysis. Med Decis Making 2016; 25:387-97. [PMID: 16061890 DOI: 10.1177/0272989x05278432] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background . To better inform clinicians on the optimal management of patients on oral anticoagulation who need to undergo surgery or invasive procedures, the authors performed a decision analysis examining whether a perioperative aggressive or minimalist strategy results in greater quality-adjusted survival. Methods . A decision analysis model was created comparing withholding warfarin (minimalist strategy) to withholding warfarin and administering treatment-dose subcutaneous low-molecular-weight heparin (LMWH) or intravenous heparin perioperatively (aggressive strategy). The base-case analysis examined a hypothetical 60-year-old hypertensive individual with mechanical aortic valve replacement undergoing major abdominal surgery. A probabilistic sensitivity analysis was performed using a Monte Carlo simulation with quality-adjusted life expectancy (QALE) as the outcome. Secondary analyses examined patients with a mechanical mitral valve and atrial fibrillation. Sensitivity analyses were performed for each variable. Results . Under the base-case scenario, the minimalist strategy was preferred for 78% of trials in the Monte Carlo simulation, with a mean benefit of 0.003 years (95% confidence interval, -0.005 years to 0.011 years). Sensitivity analyses based on point estimates indicate that the aggressive strategy is preferred when the annual stroke rate is >5.6% or the increase in postoperative major bleeding induced by heparin is <2.0%; however, the benefit is small over the range of plausible values. Conclusions . For most patients with a mechanical aortic valve or atrial fibrillation undergoing major surgery, a minimalist strategy of simply withholding oral anticoagulation provides similar QALE as an aggressive strategy of administering perioperative subcutaneous LMWH or intravenous heparin. The aggressive therapy provides greater QALE for patients at higher risk of stroke (e.g., mechanical mitral valves), although the benefit is small.
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Affiliation(s)
- Andrew S Dunn
- Division of General Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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16
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Sridhar ARM, Yarlagadda V, Kanmanthareddy A, Parasa S, Maybrook R, Dawn B, Reddy YM, Lakkireddy D. Incidence, predictors and outcomes of hematoma after ICD implantation: An analysis of a nationwide database of 85,276 patients. Indian Pacing Electrophysiol J 2016; 16:159-164. [PMID: 27979375 PMCID: PMC5153424 DOI: 10.1016/j.ipej.2016.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/21/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Pocket hematoma is one of the most common complications following cardiac device implantation. This study examined the impact of this complication on in-hospital outcomes following Implantable Cardioverter Defibrillator (ICD) implantation. METHODS Data from Nationwide Inpatient Sample (NIS) 2010 was queried to identify all primary implantations of ICDs and Cardiac Resynchronization Therapy Defibrillators (CRT-D) during the year 2010 using ICD-9 codes. We then identified the patients who experienced a procedure related hematoma during the hospital stay. We compared the outcomes of the patients with and without a hematoma complication. All analyses were performed using SPSS 20 complex samples using appropriate weights to adjust for the complex sampling design of the national database. RESULTS Out of a total of 85,276 primary ICD implantations in the year 2010, 2233 (2.6% of the implantations) were complicated by a hematoma. Increased age (p < 0.001), and comorbidities such as congestive heart failure (odds ratio (OR) - 1.86, p < 0.001), coagulopathy (OR - 2.3, p < 0.001) and renal failure (OR - 1.52, p < 0.001) were associated with an increased risk of pocket hematoma formation. Patients who developed a hematoma had a longer hospitalization (9.1 days versus 5.5 days, p < 0.001) and higher in-hospital costs ($56,545 versus $47,015, p < 0.001) compared to patients who did not have a hematoma. Overall mortality associated with ICD implantation was low (0.6%), and hematoma formation did not adversely affect mortality (0.6% versus 0.4%, p = 0.63). CONCLUSION Hematoma occurs infrequently after ICD implantation, however, it adversely impacts the cost of procedure and length of stay.
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Affiliation(s)
| | - Vivek Yarlagadda
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, The University of Kansas Hospital & Medical Center, 3901 Rainbow Boulevard MS 4023, Kansas City, KS 66160-7200, USA
| | - Arun Kanmanthareddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, The University of Kansas Hospital & Medical Center, 3901 Rainbow Boulevard MS 4023, Kansas City, KS 66160-7200, USA
| | - Sravanthi Parasa
- The University of Kanas Medical Center, 3901 Rainbow Boulevard MS 4023, Kansas City, KS 66160-7200, USA
| | - Ryan Maybrook
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, The University of Kansas Hospital & Medical Center, 3901 Rainbow Boulevard MS 4023, Kansas City, KS 66160-7200, USA
| | - Buddhadeb Dawn
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, The University of Kansas Hospital & Medical Center, 3901 Rainbow Boulevard MS 4023, Kansas City, KS 66160-7200, USA
| | - Yeruva Madhu Reddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, The University of Kansas Hospital & Medical Center, 3901 Rainbow Boulevard MS 4023, Kansas City, KS 66160-7200, USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, The University of Kansas Hospital & Medical Center, 3901 Rainbow Boulevard MS 4023, Kansas City, KS 66160-7200, USA.
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Essebag V, Healey JS, Ayala-Paredes F, Kalfon E, Coutu B, Nery P, Verma A, Sapp J, Philippon F, Sandhu RK, Coyle D, Eikelboom J, Wells G, Birnie DH. Strategy of continued vs interrupted novel oral anticoagulant at time of device surgery in patients with moderate to high risk of arterial thromboembolic events: The BRUISE CONTROL-2 trial. Am Heart J 2016; 173:102-7. [PMID: 26920602 DOI: 10.1016/j.ahj.2015.12.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/04/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients who require perioperative anticoagulation during cardiac implantable electronic device surgery are at increased risk for bleeding complications. The BRUISE CONTROL trial demonstrated that continuing warfarin was safer than heparin bridging, reducing the incidence of clinically significant pocket hematoma. Novel oral anticoagulants are being increasingly prescribed in place of warfarin. The best perioperative management of these new anticoagulants is unknown. METHODS/DESIGN A randomized controlled trial to investigate whether a strategy of continued vs interrupted novel oral anticoagulant (dabigatran, rivaroxaban, or apixaban) at the time of device surgery, in patients with moderate to high risk of arterial thromboembolic events, reduces the incidence of clinically significant hematoma (defined as a hematoma requiring reoperation and/or resulting in prolongation of hospitalization, and/or requiring interruption of anticoagulation). The secondary outcomes include components of the primary outcome, composite of all other major perioperative bleeding events, thromboembolic events, all-cause mortality, cost-effectiveness, patient quality of life, perioperative pain, and satisfaction. Planned analyses include descriptive statistics of all baseline variables. For the primary outcome, interrupted vs continued novel oral anticoagulant arms will be compared using the χ(2) test. If any clinically significant differences are identified, a logistic regression analysis will be conducted. Quality of life will be assessed using EuroQol-5D, and perioperative pain using a visual analog scale. DISCUSSION BRUISE CONTROL-2 is a randomized trial evaluating the best strategy to manage novel oral anticoagulants at the time of device surgery. We hypothesize that device surgery can be performed safely without interruption of these medications.
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Melton BL, Howard PA, Goerdt A, Casey J. Association of Uninterrupted Oral Anticoagulation During Cardiac Device Implantation with Pocket Hematoma. Hosp Pharm 2016; 50:761-6. [PMID: 26912915 DOI: 10.1310/hpj5009-761] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE Implantation of permanent pacemakers (PPMs) or implantable cardiac defibrillators (ICDs) may be complicated by the development of pocket hematomas. Current practice guidelines provide little guidance to clinicians about the preferred strategy for chronic oral anticoagulation (OAC). The purpose of this study was to examine the frequency and clinical significance of pocket hematoma among patients receiving uninterrupted OAC during cardiac device implantation. METHODS This was a retrospective cohort study of adult patients undergoing cardiac device implantation between January 1, 2011, and December 31, 2012, at an academic teaching hospital. Medical records were reviewed for demographics, comorbidities, and medications. The primary outcome was development of pocket hematomas within 30 days of device implantation. Clinical significance was based on the need for additional intervention. Data were assessed using descriptive statistics, logistic regression, and chi-square tests. RESULTS The final cohort included 380 patients. The median age was 68.4 years, and 56.6% were male. Cardiovascular comorbidities were common. Among 80 patients receiving uninterrupted OAC, 71.3% were taking warfarin, 11.2% rivaroxaban, and 17.5% dabigatran. The incidence of pocket hematomas for the entire cohort was 9.7%, of which 1.3% were clinically significant. Pocket hematoma occurred in 21.4% of patients continued on OAC versus 7.7% of those not anticoagulated (P = .001). Pocket hematoma was more common among those receiving ICDs than PPMs (18.5% vs 5.7%, respectively; P < .001). CONCLUSIONS Continuing chronic OAC increased pocket hematoma formation but most were clinically insignificant. Pocket hematoma occurred irrespective of the oral anticoagulant drug used, but additional study is needed to determine comparative risks among the drugs.
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Affiliation(s)
- Brittany L Melton
- Assistant Professor, Department of Pharmacy Practice, University of Kansas School of Pharmacy , Lawrence, Kansas
| | - Patricia A Howard
- Professor and Vice Chair, Department of Pharmacy Practice, University of Kansas Medical Center , Kansas City, Kansas
| | - Abby Goerdt
- Clinical Pharmacist, University of Kansas Hospital , Kansas City, Kansas
| | - Jessica Casey
- Clinical Pharmacist, University of Kansas Hospital , Kansas City, Kansas
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19
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Atreya AR, Cook JR, Lindenauer PK. Complications arising from cardiac implantable electrophysiological devices: review of epidemiology, pathogenesis and prevention for the clinician. Postgrad Med 2016; 128:223-30. [DOI: 10.1080/00325481.2016.1151327] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Daubert JC, Mabo P. Continue or withhold oral anticoagulation in high-risk patients undergoing pacemaker or ICD implantation. Eur Heart J 2015; 30:1828a-1828c. [PMID: 19717508 DOI: 10.1093/eurheartj/ehn491] [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] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jean-Claude Daubert
- Service de Cardiologie et Maladies Vasculaires, Centre Hospitalier Universitaire, 35000 Rennes, France
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21
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Crosato M, Calzolari V, Franceschini Grisolia E, Daniotti A, Baldessin F, Mantovan R, Olivari Z. Implanting cardiac rhythm devices during uninterrupted warfarin therapy. J Cardiovasc Med (Hagerstown) 2015; 16:503-6. [DOI: 10.2459/jcm.0000000000000011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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22
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DE Sensi F, Miracapillo G, Cresti A, Severi S, Airaksinen KEJ. Pocket Hematoma: A Call for Definition. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:909-13. [PMID: 25974662 DOI: 10.1111/pace.12665] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 04/22/2015] [Accepted: 05/04/2015] [Indexed: 02/06/2023]
Abstract
Pocket hematoma is a common complication of cardiac implantable electronic device procedures and a potential risk factor for device infections, especially in patients on oral anticoagulation or antiplatelet treatment. There is a wide variability in the incidence of pocket hematoma and bleeding complications in the literature and the major cause for this seems to be the variability of the used definitions for hematomas. The lack of generally accepted definition for pocket hematoma renders the comparisons across the studies difficult. In this article, we briefly review the current literature on this issue and propose a uniform definition for pocket hematoma and criteria for grading the severity of hematoma in clinical practice and research.
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Affiliation(s)
| | | | | | - Silva Severi
- Cardiology Unit, Misericordia Hospital, Grosseto, Italy
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23
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Zaca V, Marcucci R, Parodi G, Limbruno U, Notarstefano P, Pieragnoli P, Di Cori A, Bongiorni MG, Casolo G. Management of antithrombotic therapy in patients undergoing electrophysiological device surgery. Europace 2015; 17:840-54. [DOI: 10.1093/europace/euu357] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/13/2014] [Indexed: 11/14/2022] Open
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SANT'ANNA ROBERTOT, LEIRIA TIAGOL, NASCIMENTO THAIS, SANT'ANNA JOÃORICARDOM, KALIL RENATOAK, LIMA GUSTAVOG, VERMA ATUL, HEALEY JEFFS, BIRNIE DAVIDH, ESSEBAG VIDAL. Meta-Analysis of Continuous Oral Anticoagulants Versus Heparin Bridging in Patients Undergoing CIED Surgery: Reappraisal after the BRUISE Study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 38:417-23. [DOI: 10.1111/pace.12557] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/02/2014] [Accepted: 11/13/2014] [Indexed: 01/22/2023]
Affiliation(s)
| | - TIAGO L. LEIRIA
- Instituto de Cardiologia do Rio Grande do Sul; Porto Alegre Brazil
| | | | | | | | - GUSTAVO G. LIMA
- Instituto de Cardiologia do Rio Grande do Sul; Porto Alegre Brazil
| | - ATUL VERMA
- Southlake Regional Health Centre; Newmarket Canada
| | | | | | - VIDAL ESSEBAG
- McGill University Health Centre; Montréal Canada
- Hôpital Sacré-Coeur de Montréal; Montréal Canada
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25
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January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199-267. [PMID: 24682347 PMCID: PMC4676081 DOI: 10.1161/cir.0000000000000041] [Citation(s) in RCA: 919] [Impact Index Per Article: 91.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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26
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De Sensi F, Paneni F, Addonisio L, Breschi M, Miracapillo G, Severi S. Intrinsic bleeding risk in patients with uninterrupted oral anticoagulation undergoing cardiac implantable electronic device procedures: A pilot study. Int J Cardiol 2014; 176:1420-2. [DOI: 10.1016/j.ijcard.2014.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 07/29/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
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27
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DU LING, ZHANG YONG, WANG WEIZONG, HOU YINGLONG. Perioperative Anticoagulation Management in Patients on Chronic Oral Anticoagulant Therapy Undergoing Cardiac Devices Implantation: A Meta-Analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:1573-86. [PMID: 25234639 DOI: 10.1111/pace.12517] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 07/20/2014] [Accepted: 07/25/2014] [Indexed: 11/29/2022]
Affiliation(s)
- LING DU
- Department of Cardiology; Shandong Provincial Qianfoshan Hospital; Shandong University; Jinan China
- Department of Clinical Pharmacy (seven-year); School of Pharmaceutical Sciences; Shandong University; Jinan China
| | - YONG ZHANG
- Department of Cardiology; Shandong Provincial Qianfoshan Hospital; Shandong University; Jinan China
| | - WEIZONG WANG
- Department of Cardiology; Shandong Provincial Qianfoshan Hospital; Shandong University; Jinan China
- School of medicine; Shandong University; Jinan China
| | - YINGLONG HOU
- Department of Cardiology; Shandong Provincial Qianfoshan Hospital; Shandong University; Jinan China
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28
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Schulman S, Healey JS, Douketis JD, Delaney J, Morillo CA. Reduced-dose warfarin or interrupted warfarin with heparin bridging for pacemaker or defibrillator implantation: a randomized trial. Thromb Res 2014; 134:814-8. [PMID: 25127655 DOI: 10.1016/j.thromres.2014.07.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/09/2014] [Accepted: 07/21/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Perioperative management with reduced-dose warfarin is of potential interest by eliminating the need for bridging while still maintaining a degree of anticoagulation. The outcomes of this regimen have not been well determined. METHODS In a randomized controlled trial we compared two regimens for management of anticoagulation with warfarin in patients with implantation of a pacemaker or defibrillator. Half dose of warfarin for 3-6 days, depending on the baseline international normalized ratio (INR), before surgery aiming at an INR of ≤ 1.7 was compared with interrupted warfarin for 5 days with preoperative bridging with low-molecular-weight heparin (LMWH) at therapeutic dose for 2.5 days. Main safety outcome was pocket hematoma. Secondary outcomes were major bleeding, thromboembolism - all within 1 month, days of hospitalization and number of patients requiring correction of INR with vitamin K. RESULTS The study was planned for 450 patients but it was discontinued prematurely due to a change in practice. Pocket hematoma occurred in 4 of 85 patients (5%) randomized to the bridged regimen and in 3 of 86 patients (3%) randomized to reduced-dose warfarin. One pocket hematoma in each group was severe. There were no major hemorrhages or thromboembolism within the 1-month window. Duration of hospitalization was similar in the two groups. Correction of INR the day before surgery with vitamin K had to be used for significantly more patients in the reduced-dose warfarin group (41%) than in the bridged regimen group (6%). CONCLUSION The reduced-dose warfarin regimen appeared to have similar safety after device implantation as interrupted warfarin with preoperative LMWH bridging. Due to premature discontinuation no firm conclusion can be drawn. The reduced-dose warfarin regimen often failed to achieve the intended preoperative INR. ClinicalTrials.gov Identifier: NCT 02094157.
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Affiliation(s)
- S Schulman
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada; Department of Medicine, Thrombosis Service, McMaster University, Hamilton, ON, Canada; Karolinska Institutet, Stockholm, Sweden.
| | - J S Healey
- Department of Medicine, Thrombosis Service, McMaster University, Hamilton, ON, Canada; Arrhythmia Services, Cardiology Division, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - J D Douketis
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada; Department of Medicine, Thrombosis Service, McMaster University, Hamilton, ON, Canada
| | - J Delaney
- Department of Medicine, Thrombosis Service, McMaster University, Hamilton, ON, Canada
| | - C A Morillo
- Department of Medicine, Thrombosis Service, McMaster University, Hamilton, ON, Canada; Arrhythmia Services, Cardiology Division, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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29
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2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1-76. [PMID: 24685669 DOI: 10.1016/j.jacc.2014.03.022] [Citation(s) in RCA: 2854] [Impact Index Per Article: 285.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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30
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Giglia TM, Massicotte MP, Tweddell JS, Barst RJ, Bauman M, Erickson CC, Feltes TF, Foster E, Hinoki K, Ichord RN, Kreutzer J, McCrindle BW, Newburger JW, Tabbutt S, Todd JL, Webb CL. Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease. Circulation 2013; 128:2622-703. [DOI: 10.1161/01.cir.0000436140.77832.7a] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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31
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Tyagi G, Pai SM, Pai RG. Cardiac rhythm device surgery with uninterrupted oral anticoagulation. Future Cardiol 2013; 9:763-6. [PMID: 24180532 DOI: 10.2217/fca.13.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Current guidelines recommend interrupting anticoagulation and bridging therapy with heparin or low-molecular-weight heparin for cardiac rhythm device surgeries in patients with high thrombotic risk. However, there are some studies that suggest continuing warfarin may be safe. The study by Birnie et al. investigates this important clinical question in a randomized controlled trial setting. They randomly assigned 681 patients with high thrombotic risk (5% or more per year), in 18 centers, to receive either stopping warfarin combined with heparin bridging (standard of care) or continued uninterrupted warfarin therapy for cardiac rhythm device surgery. The trial was terminated after a second prespecified interim analysis by the data and safety monitoring board. Clinically significant device-pocket hematoma was noted in 12 out of 343 patients (3.5%) in the uninterrupted warfarin group, compared with 54 out of 338 (16.0%) in the heparin-bridging group (relative risk: 0.19; 95% CI: 0.10-0.36; p < 0.001). Uninterrupted warfarin was associated with better patient satisfaction, and there was no significant difference in thromboembolic or surgical complications between the two groups. These results demonstrate that device surgeries can be safely performed with continued warfarin, and bridging with heparin is associated with high risk of device-pocket hematoma.
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Affiliation(s)
- Gaurav Tyagi
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
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32
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KAHWASH RAMI, DAOUD EMILEG. Just Because You Can, Does That Mean You Should? J Cardiovasc Electrophysiol 2013; 24:1130-1. [DOI: 10.1111/jce.12216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- RAMI KAHWASH
- Ross Heart Hospital, Wexner Medical Center; the Ohio State University; Columbus Ohio USA
| | - EMILE G. DAOUD
- Ross Heart Hospital, Wexner Medical Center; the Ohio State University; Columbus Ohio USA
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Airaksinen KJ, Korkeila P, Lund J, Ylitalo A, Karjalainen P, Virtanen V, Raatikainen P, Koivisto UM, Koistinen J. Safety of pacemaker and implantable cardioverter–defibrillator implantation during uninterrupted warfarin treatment — The FinPAC study. Int J Cardiol 2013; 168:3679-82. [DOI: 10.1016/j.ijcard.2013.06.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 04/04/2013] [Accepted: 06/15/2013] [Indexed: 11/27/2022]
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Thrombocytopenia, Dual Antiplatelet Therapy, and Heparin Bridging Strategy Increase Pocket Hematoma Complications in Patients Undergoing Cardiac Rhythm Device Implantation. Can J Cardiol 2013; 29:1110-7. [DOI: 10.1016/j.cjca.2012.12.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 12/13/2012] [Accepted: 12/13/2012] [Indexed: 11/21/2022] Open
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35
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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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Perioperative management of anticoagulation in patients on warfarin therapy undergoing surgery for cardiac implantable electronic devices. J Arrhythm 2013. [DOI: 10.1016/j.joa.2013.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Birnie DH, Healey JS, Wells GA, Verma A, Tang AS, Krahn AD, Simpson CS, Ayala-Paredes F, Coutu B, Leiria TLL, Essebag V. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med 2013; 368:2084-93. [PMID: 23659733 DOI: 10.1056/nejmoa1302946] [Citation(s) in RCA: 380] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Many patients requiring pacemaker or implantable cardioverter-defibrillator (ICD) surgery are taking warfarin. For patients at high risk for thromboembolic events, guidelines recommend bridging therapy with heparin; however, case series suggest that it may be safe to perform surgery without interrupting warfarin treatment. There have been few results from clinical trials to support the safety and efficacy of this approach. METHODS We randomly assigned patients with an annual risk of thromboembolic events of 5% or more to continued warfarin treatment or to bridging therapy with heparin. The primary outcome was clinically significant device-pocket hematoma, which was defined as device-pocket hematoma that necessitated prolonged hospitalization, interruption of anticoagulation therapy, or further surgery (e.g., hematoma evacuation). RESULTS The data and safety monitoring board recommended termination of the trial after the second prespecified interim analysis. Clinically significant device-pocket hematoma occurred in 12 of 343 patients (3.5%) in the continued-warfarin group, as compared with 54 of 338 (16.0%) in the heparin-bridging group (relative risk, 0.19; 95% confidence interval, 0.10 to 0.36; P<0.001). Major surgical and thromboembolic complications were rare and did not differ significantly between the study groups. They included one episode of cardiac tamponade and one myocardial infarction in the heparin-bridging group and one stroke and one transient ischemic attack in the continued-warfarin group. CONCLUSIONS As compared with bridging therapy with heparin, a strategy of continued warfarin treatment at the time of pacemaker or ICD surgery markedly reduced the incidence of clinically significant device-pocket hematoma. (Funded by the Canadian Institutes of Health Research and the Ministry of Health and Long-Term Care of Ontario; BRUISE CONTROL ClinicalTrials.gov number, NCT00800137.).
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Affiliation(s)
- David H Birnie
- University of Ottawa Heart Institute, Ottawa, ON, Canada.
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SCHWERG MARIUS, BALDENHOFER GERD, DREGER HENRYK, BONDKE HANSJÜRGEN, STANGL KARL, LAULE MICHAEL, MELZER CHRISTOPH. Complete Atrioventricular Block after TAVI: When Is Pacemaker Implantation Safe? Pacing Clin Electrophysiol 2013; 36:898-903. [DOI: 10.1111/pace.12150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 01/28/2013] [Accepted: 02/18/2013] [Indexed: 11/29/2022]
Affiliation(s)
- MARIUS SCHWERG
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte; Charité-Universitätsmedizin Berlin; Germany
| | - GERD BALDENHOFER
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte; Charité-Universitätsmedizin Berlin; Germany
| | - HENRYK DREGER
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte; Charité-Universitätsmedizin Berlin; Germany
| | - HANSJÜRGEN BONDKE
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte; Charité-Universitätsmedizin Berlin; Germany
| | - KARL STANGL
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte; Charité-Universitätsmedizin Berlin; Germany
| | - MICHAEL LAULE
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte; Charité-Universitätsmedizin Berlin; Germany
| | - CHRISTOPH MELZER
- Medizinische Klinik für Kardiologie und Angiologie; Campus Mitte; Charité-Universitätsmedizin Berlin; Germany
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Rowley CP, Bernard ML, Brabham WW, Netzler PC, Sidney DS, Cuoco F, Sturdivant JL, Leman RB, Wharton JM, Gold MR. Safety of continuous anticoagulation with dabigatran during implantation of cardiac rhythm devices. Am J Cardiol 2013; 111:1165-8. [PMID: 23360767 DOI: 10.1016/j.amjcard.2012.12.046] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 12/23/2012] [Accepted: 12/23/2012] [Indexed: 10/27/2022]
Abstract
The perioperative bleeding risk associated with therapeutic anticoagulation at cardiac implantable electronic device implantation has previously been demonstrated to vary by the specific anticoagulant used. Although uninterrupted anticoagulation with warfarin appears to be safe, heparin products have been shown to increase the risk of perioperative bleeding. However, the risk associated with cardiac implantable electronic device implantation with anticoagulation using dabigatran, a novel oral direct thrombin inhibitor, is not known. We performed a prospective observational study of patients receiving dabigatran for anticoagulation who underwent cardiac implantable electronic device implantation from June 2011 through May 2012. The study end points included thromboembolic and bleeding complications within 30 days of surgery. Major bleeding complications were defined as bleeding requiring surgical intervention, prolongation of hospitalization, and discontinuation of the anticoagulant or transfusion of blood products within 30 days of surgery. Minor bleeding complications included the development of a hematoma not requiring additional intervention. The thrombotic end points included stroke, transient ischemic attack, myocardial infarction, pulmonary embolism, and deep vein thrombosis. A total of 25 patients were identified for inclusion. During the index hospitalization, no thromboembolic or bleeding complications developed. No major bleeding complications occurred within 30 days of surgery. One minor bleeding event (4%) occurred within 30 days of surgery in 1 patient who was also receiving dual antiplatelet therapy. In conclusion, although no thromboembolic or major bleeding events were observed, additional studies are required to define the optimal antithrombotic management in the perioperative period.
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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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Palmisano P, Accogli M, Zaccaria M, Luzzi G, Nacci F, Anaclerio M, Favale S. Rate, causes, and impact on patient outcome of implantable device complications requiring surgical revision: large population survey from two centres in Italy. Europace 2013; 15:531-40. [PMID: 23407627 DOI: 10.1093/europace/eus337] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
AIMS The long-term impact of implantable device-related complications on the patient outcome has not been thoroughly evaluated. The aims of this retrospective, bi-centre study were to analyse the rate and nature of device-related complications requiring surgical revision in a large series of patients undergoing device implantation, elective generator replacement and pacing system upgrade and to systematically assess the impact of such complications on patient outcome and healthcare utilization. METHODS AND RESULTS Data from 2671 consecutive procedures (1511 device implantations, 1034 elective generator replacements, and 126 pacing system upgrades) performed between January 2006 and March 2011 were retrospectively analysed. The outcome measures recorded were complication-related mortality, number of re-operations, need for complex surgical procedures, number of re-hospitalizations, and additional hospital treatment days. Over a median follow-up of 27 months, the overall rate of complications was 2.8% per procedure-year [9.5% in cardiac resynchronisation therapy (CRT) device implantation, 6.1% in pacing system upgrade, 3.5% in implantable cardioverter defibrillator implantation, 1.7% in pacemaker implantation, and 1.7% in generator replacement). The procedure with the highest risk of complications was CRT device implantation (odds ratio: 6.6; P < 0.001); these complications primarily involved coronary sinus lead dislodgement and device infection. Patients with complications had a significantly higher number of device-related hospitalizations (2.3 ± 0.6 vs. 1.0 ± 0.1; P < 0.001) and hospital treatment days (15.7 ± 25.1 vs. 3.6 ± 1.1; P < 0.001) than those without complications. Device infection was the complication with the greatest negative impact on patient outcome. CONCLUSION Cardiac resynchronisation therapy implantation was the procedure with the highest risk of complications requiring surgical revision. Complications were associated with substantial clinical consequences and a significant increase in the number and length of hospitalizations.
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Affiliation(s)
- Pietro Palmisano
- Cardiology Unit, 'Card. G. Panico' Hospital, Tricase (Le), Italy.
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Schulman S, Schoenberg J, Divakara Menon S, Spyropoulos AC, Healey JS, Eikelboom JW. Anticoagulation management in patients with mechanical heart valves having pacemaker or defibrillator insertion. Thromb Res 2013; 131:300-3. [PMID: 23369688 DOI: 10.1016/j.thromres.2013.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 01/04/2013] [Accepted: 01/08/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND In patients with a high risk for stroke and having invasive procedures with a high risk for bleeding it is unclear how anticoagulant therapy should be managed. METHODS We reviewed data from all patients with mechanical heart valves, who had elective insertion or replacement of pacemaker or implantable cardioverter defibrillator (ICD) during the past 8years at our hospital. Data on anticoagulant treatment, pocket hematoma and thromboembolic complications were captured. RESULTS Of the 111 patients reviewed, 68 (61%) had a mechanical valve in the mitral position with or without other valves replaced and 43 (39%) had a mechanical valve only in the aortic position. Fifty-nine (53%) were undergoing replacement for their device. Six patients received a tapered warfarin regimen and 102 received preoperative bridging anticoagulation of whom 12 also received postoperative bridging. One stroke occurred 40days after pacemaker replacement in a patient with mitral mechanical valve and without postoperative bridging. Six patients (5.5%) developed pocket hematoma without a significant association to postoperative bridging, type of mechanical valve or to type of device. Predictors for pocket hematoma appeared to be replacement surgery (odds ratio 12.5; 95% confidence interval [CI], 0.69-228) and an international normalized ratio of 1.5 or higher on the day of surgery (odds ratio 8.4; 95% CI, 0.96-68.1). CONCLUSION We found a low risk for stroke in the absence of postoperative bridging. For patients with device replacement surgery reversal of the anticoagulant effect at the time of procedure might reduce the risk for pocket hematoma, but this requires prospective evaluation including the risk of thromboembolism.
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Affiliation(s)
- S Schulman
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada; Department of Medicine, Thrombosis Service, McMaster University, Hamilton, ON, Canada.
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Meta-analysis of safety and efficacy of uninterrupted warfarin compared to heparin-based bridging therapy during implantation of cardiac rhythm devices. Am J Cardiol 2012; 110:1482-8. [PMID: 22906894 DOI: 10.1016/j.amjcard.2012.06.057] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 06/25/2012] [Accepted: 06/25/2012] [Indexed: 11/21/2022]
Abstract
Optimal management of perioperative anticoagulation in patients undergoing pacemaker or implantable cardioverter-defibrillator implantation is not yet established. We performed a meta-analysis of the published literature to assess the safety and efficacy of perioperative heparin-based bridging therapy versus uninterrupted warfarin therapy in patients undergoing pacemaker or implantable cardioverter-defibrillator implantation. We performed a systematic review of MEDLINE (1950 to 2012), EMBASE (1988 to 2012), Cochrane Controlled Trials Register (fourth quarter 2011), and reports presented at scientific meetings (1994 to 2011). Randomized controlled trials, case-control, or cohort studies comparing the safety and efficacy of uninterrupted warfarin therapy to heparin-based bridging therapy were eligible. Outcomes reported in eligible studies were rates of bleeding and thromboembolic events. Of 3,195 reports initially reviewed, we identified 8 studies enrolling 2,321 patients for the meta-analysis. Maintenance of therapeutic warfarin was associated with significantly lower bleeding postoperatively compared to heparin-based bridging therapy (odds ratio 0.30, 95% confidence interval 0.18 to 0.50, p <0.01). There was no significant difference in risk of thromboembolic events between these 2 strategies (odds ratio 0.65, 95% confidence interval 0.14 to 3.02, p = 0.58). In conclusion, strategy of uninterrupted warfarin therapy throughout pacemaker or implantable cardioverter-defibrillator implantation is associated with decreased risk of bleeding without increasing risk of thromboembolic events. This strategy is a viable alternative to heparin-based bridging therapy.
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PERRIN MARKJ, VEZI BRIANZ, HA ANDREWC, KEREN ARIEH, NERY PABLOB, BIRNIE DAVIDH. Anticoagulation Bridging Around Device Surgery: Compliance with Guidelines. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1480-6. [DOI: 10.1111/j.1540-8159.2012.03516.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Choudhuri I, Desai D, Walburg J, August P, Keller SI, Suri R. Feasibility of early discharge after implantable cardioverter-defibrillator procedures. J Cardiovasc Electrophysiol 2012; 23:1123-9. [PMID: 22882572 DOI: 10.1111/j.1540-8167.2012.02367.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Registry data demonstrate considerably low complication rates after implantable cardioverter-defibrillator (ICD) procedures for primary prevention of sudden death. Yet standard of care includes postimplant overnight in-hospital observation that may levy substantial unnecessary financial burden on health care systems. In appropriate patients, discharge soon after implant could translate into significant cost savings, if such practice does not result in complications. We applied a simple clinical algorithm to assess feasibility of discharge on the same day of ICD implantation in patients at low risk for procedural complications. METHODS We prospectively randomized primary prevention ICD candidates at low risk for complications (not pacing-dependent or requiring bridging heparin anticoagulation) to next-day discharge with overnight in-hospital observation, or same-day discharge with remote monitoring for 24 hours after ICD implant. Implants were performed via cephalic vein access, and randomization occurred after 4-hours clinical observation and device interrogation. All patients were followed for a minimum of 6 weeks to assess acute procedural complications. RESULTS 71 patients comprised the study cohort (mean age 62, 79% male) after 3 were excluded. The most common indication for ICD implant was ischemic cardiomyopathy with ejection fraction ≤35%. Device data obtained through 24-hour remote monitoring was comparable to 4-hour postimplant parameters in same-day discharge patients. No acute complications occurred in same-day discharge patients; 1 next-day discharge patient developed pneumothorax. CONCLUSION ICD implantation with same-day discharge is reasonable in patients at low risk for complications. Remote monitoring can be useful in indicating lead-parameter stability during the immediate postoperative period.
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Affiliation(s)
- Indrajit Choudhuri
- Division of Cardiology, Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin, USA
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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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Bernard ML, Shotwell M, Nietert PJ, Gold MR. Meta-analysis of bleeding complications associated with cardiac rhythm device implantation. Circ Arrhythm Electrophysiol 2012; 5:468-74. [PMID: 22534249 DOI: 10.1161/circep.111.969105] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many patients receiving cardiac rhythm devices have conditions requiring antiplatelet (AP) and/or anticoagulant (AC) therapy. Current guidelines recommend a heparin-bridging strategy (HBS) for anticoagulated patients with moderate/high risk for thrombosis. Several studies reported lower bleeding risk with continued oral anticoagulation rather than HBS. The best strategy for perioperative management of patients on AP therapy is less clear. The present study was designed as a meta-analysis of device implantation-associated bleeding complications using different AC/AP therapies. METHODS AND RESULTS PubMed and Cochrane Database searches identified articles based on design, outcomes, and available data. Device recipients were grouped as follows: no therapy, aspirin only, AC held, AC continued, dual AP, and HBS. The primary outcome was defined as a bleeding complication including hematoma, transfusion, or prolonged hospital stay. Thirteen articles were identified for analysis including 5978 patients. The combined incidence of bleeding complications was 274 of 5978 (4.6%), ranging from 2.2% (no therapy) to 14.6% (HBS). The estimated odds of bleeding were increased by 8.3 (95% CI, 5.5-12.9) times in the HBS group, 5.0 (95% CI, 3.0-8.3) for dual AP therapy, 1.7 (95% CI, 1.0-3.1) for AC held, 1.6 (95% CI, 0.9-2.6) for AC continued, and 1.5 (95% CI, 0.9-2.3) for aspirin only relative to the no therapy group. HBS significantly increased bleeding events compared with holding or continuing AC. Continuing AC did not increase bleeding events compared with no therapy. CONCLUSIONS Continuing AC appears safer than HBS for device implantation. Dual AP therapy but not continuing AC carries a significant risk of bleeding.
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Affiliation(s)
- Michael L Bernard
- Division of Cardiology, Medical University of South Carolina, Charleston, SC 29425, USA
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Fujiwara R, Yoshida A, Takei A, Fukuzawa K, Takami K, Takami M, Tanaka S, Ito M, Imamura K, Hirata KI. WITHDRAWN: “Heparin bridging” increases the risk of bleeding complications in patients with prosthetic devices and receiving anticoagulation therapy. J Arrhythm 2012. [DOI: 10.1016/j.joa.2011.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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“Heparin bridging” increases the risk of bleeding complications in patients undergoing anticoagulation therapy and device implantation. J Arrhythm 2012. [DOI: 10.1016/j.joa.2012.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Garwood CL, Hwang JM, Moser LR. Striking a balance between the risks and benefits of anticoagulation bridge therapy in patients with atrial fibrillation: clinical updates and remaining controversies. Pharmacotherapy 2012; 31:1208-20. [PMID: 22122182 DOI: 10.1592/phco.31.12.1208] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Long-term anticoagulation with a vitamin K antagonist (VKA) or the new agent dabigatran is recommended to decrease stroke risk in patients with atrial fibrillation. When patients with atrial fibrillation undergo initiation or interruption of VKA therapy, or experience an isolated subtherapeutic international normalized ratio (INR), bridge therapy with a parenteral anticoagulant may be considered. To describe the literature for anticoagulation bridge therapy in patients with atrial fibrillation, we conducted a MEDLINE search (1966-February 2011) of the English-language literature to identify related studies. Ongoing clinical trials were identified through a search of the ClinicalTrials.gov registry. Major national and international guidelines were gathered and evaluated. Additional literature was obtained through review of relevant references of the identified articles. Bridging is not supported by guidelines or clinical trials for patients starting VKA therapy for atrial fibrillation. A subtherapeutic INR value during long-term VKA therapy may be associated with increased thromboembolic events, but the benefit of bridging has not been demonstrated. When VKA therapy is interrupted for procedures, retrospective and cohort data suggest that the decision to bridge should be based on a patient's thromboembolic and bleeding risks associated with the procedure. Typically, it is recommended to use bridge therapy in patients with atrial fibrillation at high risk for thromboembolism, but the benefit of bridging is less clear in patients at low risk. Not all procedures necessitate anticoagulation interruption. Recent trials suggest that VKAs can be continued when patients are undergoing cardiac device procedures and some types of radiofrequency ablation. Several clinical trials are ongoing that will provide more definitive guidance for perioperative anticoagulation management of patients with atrial fibrillation. Patients taking dabigatran are unlikely to require bridge therapy because of a predictable anticoagulant effect and rapid onset of action. However, evidence for optimal perioperative management of dabigatran is needed.
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Affiliation(s)
- Candice L Garwood
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan 48201, USA.
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