Implantation of pacemakers and implantable cardioverter defibrillators in orally anticoagulated patients

Retrospective study of post-operative infections in implantable cardiac devices in a cardiac tertiary care center

BACKGROUND

The rise in the incidence of implantation is one of the main causes behind the increased rate of CIED infection, which is considered as a serious life-threatening complication. The need of risk factor assessment has become a necessity to prevent further complications and provide prompt management.

OBJECTIVES

Identify the risk factors of infection postoperatively among patients who have implantable cardiac devices.

DESIGN

A retrospective case-control study.

SETTINGS

Cardiac center for adults.

PATIENTS AND METHODS

The study included all adult patients (≥14 years of age) of all nationalities who underwent cardiac electronic device implantation that was managed in the cardiac center between January 2012 to December 2018.

MAIN OUTCOME MEASURES

Cardiac device infection and associated risk factors.

SAMPLE SIZE

213, including 23 (10.8%) infected case patients and 190 (89.2%) non-infected controls.

RESULTS

The mean (SD) age of non-infected patients was 45.0 (12.7) years compared with 61.7 (13.7) for infected patients (P<.0001). Anticoagulant use, hypertension, dysplipdemia and age were the most common patient-related risk factors associated with infection. For procedural and post-procedural risk factors, the risk of infection increased as the number of leads and length of procedure increased. The device most often related to infection was the pacemaker. In the multivariate analysis, longer procedure, greater number of leads, older age, anticoagulant use, and implanted pacemaker device were independently associated with infection.

CONCLUSION

We advise the prompt use of strict preoperative antiseptic prophylaxis measures and follow-up for post-implant patients along with patient education for early signs of infections, which will lead to improvement of both diagnosis and treatment quality for our patients in addition to reducing the economic impact on the health care system by minimizing infectious complications.

LIMITATIONS

Single tertiary center study, small sample size.

CONFLICT OF INTEREST

None.

The anatomical relationship between the axillary artery and vein investigated by radial coronary angiography

AIMS

To reduce the risk of inadvertent arterial puncture and bleeding, we aimed to define a safe puncture site by demonstrating the relation of the axillary artery and vein.

METHODS

The anatomical course and relation as well as crossover sites of the axillary artery and vein, the presence of small arterial bridges over the axillary vein, and validation of commonly preferred axillary venous puncture sites were determined by simultaneous ipsilateral venography in patients (n  =  111; 80 men, age 60 ± 10 years) who underwent coronary angiography by radial artery access.

RESULTS

The axillary vein was detected at the first costa-clavicular intersection in 62% and at the second anterior and third posterior costal intersection in 60% of the patients. Small arterial bridges over the axillary vein were observed in 77% of the patients and more frequently in females and body mass index ≥25 kg/m2 (P  =  0.034 and P  =  0.03, respectively). The axillary artery crossed the vein in 24% of the patients and almost always within the region close to the first costa-clavicular intersection site.

CONCLUSION

Our study demonstrated a high crossover rate (24%) of axillary artery and vein and a high degree of variation in the course of axillary vein. Small arterial bridges over the axillary vein were observed in 77% of the patients.

Management of Perioperative Anticoagulation for Device Implantation

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.

Clinical analysis of the effect of anti-allergy treatment on pocket-related complications following pacemaker implantation

A total number of 339 patients who received a pacemaker implantation between June 2012 and June 2014 at Tongji Hospital of Tongji Medical College (Wuhan, China) were investigated in the present study. The aims of the present study were to explore the risk factors of pocket hematoma following pacemaker implantation, and to analyze the effect of anti-allergy treatment on pocket-related complications following pacemaker implantation. Predictors of hematoma occurrence were determined and analyzed via a Chi-square test. Patients suffering from pocket hematoma, which were indicated to be partially caused by an allergic reaction to the pacemaker component, were distinguished by routine blood parameters. Furthermore, the pacemaker component was distinguished by histopathological examinations in one patient. Promethazine (25 mg/day) was used to treat allergic patients. The results demonstrated that in patients with a history of allergies, the rate of pocket hematoma was significantly higher when compared with patients without a history of allergies (22.00 vs. 7.61%; P=0.027). A significantly increased incidence of hematoma was indicated in patients with a lower body mass index when compared with patients of normal weight (15.79 vs. 7.38%; P=0.042). Furthermore, implantation of larger-sized devices, such as an implantable cardioverter-defibrillator and cardiac resynchronization therapy, were significantly predictive of hematoma development (29.63 vs. 8.01%; P=0.015). Patients with diabetes were also identified to exhibit a significantly high incidence of hematoma (22.22 vs. 8.25%; P=0.023). Promethazine administration significantly decreased the incidence of re-operating (P=0.017) and the duration of hospital stay (P=0.038) in patients whose pocket hematoma was caused by an allergy. In conclusion, promethazine may be a beneficial agent to treat pocket hematoma caused by allergic reactions following pacemaker surgery.

Risk factors associated with bleeding after multi antithrombotic therapy during implantation of cardiac implantable electronic devices

Previous studies showed that continuous anticoagulation or single antiplatelet therapy during implantations of cardiac implantable electronic devices (CIED) was relatively safe. However, the safety of continuous multi antithrombotic therapy (AT) in patients undergoing CIED interventions has not been clearly defined. We sought to evaluate the safety of this therapy during CIED implantations. A total of 300 consecutive patients (mean 69 years old, 171 males) with CIED implantations were enrolled in this study. The patients were divided into 6 groups [No-AT, oral anticoagulant therapy (OAT), single antiplatelet therapy (SAPT), OAT and SAPT, dual antiplatelet therapy (DAPT), triple AT (TAT)], and the perioperative complications were evaluated. Clinically significant pocket hematomas (PH) were defined as PH needing surgical intervention, prolonged hospitalizations, interruption of AT, or blood product transfusions. There were 129, 89, 49, 20, 10, and 3 patients in No-AT, OAT, SAPT, OAT + SAPT, DAPT, and TAT groups, respectively. The occurrence of clinically significant PH and thromboembolism did not differ among 6 groups (p = 0.145 and p = 0.795, respectively). However, high HAS-BLED score and valvular heart disease (VHD) were associated with clinically significant PH (p = 0.014 and p = 0.015, respectively). Continuous multi AT may be tolerated, but patients with high HAS-BLED score or VHD would require a careful attention during CIED implantations.

Analysis of Complications in Outpatient ICD Surgery On or Off Warfarin Anticoagulation

BACKGROUND

Implantable cardioverter defibrillator (ICD) implantation is being performed differently at many hospitals, with some keeping patients overnight after procedure while others discharge patients home same day. In addition, many centers are now performing ICD surgery while on warfarin anticoagulation. There are, however, limited data on outpatient ICD surgery on anticoagulated (AC) patients.

OBJECTIVE

We wished to evaluate the safety of performing outpatient ICD surgery with and without warfarin anticoagulation.

METHODS

We evaluated 866 patients who underwent outpatient ICD surgery between April 2010 and September 2014. Patients who were on novel oral anticoagulants, or did not have an international normalized ratio drawn within 24 hours of the procedure were excluded and the remainder were divided into two groups based on whether they were on (n = 230) or off (n = 518) warfarin anticoagulation. We evaluated both procedural and 30-day complications in both groups.

RESULTS

The complication rate at 30 days in the warfarin AC group was 4.3%, while in the nonanticoagulated (NAC) group was 2.9% and not significantly different (P = 0.31). However, the pocket hematoma rate in the warfarin anticoagulated group was 3.5%, as compared to the NAC group that was 0.4% (P = 0.001).

CONCLUSION

Complications from ICD surgery are low in the ambulatory setting on or off warfarin anticoagulation and appear to be comparable. However, warfarin use during ICD surgery is associated with an increased risk of pocket hematoma.

Association of Uninterrupted Oral Anticoagulation During Cardiac Device Implantation with Pocket Hematoma

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.

Dental management of a patient fitted with subcutaneous Implantable Cardioverter Defibrillator device and concomitant warfarin treatment

Automated Implantable Cardioverter Defibrillators (AICD), simply known as an Implantable Cardioverter Defibrillator (ICD), has been used in patients for more than 30 years. An Implantable Cardioverter Defibrillator (ICD) is a small battery-powered electrical impulse generator that is implanted in patients who are at a risk of sudden cardiac death due to ventricular fibrillation, ventricular tachycardia or any such related event. Typically, patients with these types of occurrences are on anticoagulant therapy. The desired International Normalized Ratio (INR) for these patients is in the range of 2–3 to prevent any subsequent cardiac event. These patients possess a challenge to the dentist in many ways, especially during oral surgical procedures, and these challenges include risk of sudden death, control of post-operative bleeding and pain.

This article presents the dental management of a 60 year-old person with an ICD and concomitant anticoagulant therapy. The patient was on multiple medications and was treated for a grossly neglected mouth with multiple carious root stumps. This case report outlines the important issues in managing patients fitted with an ICD device and at a risk of sudden cardiac death.

Reduced-dose warfarin or interrupted warfarin with heparin bridging for pacemaker or defibrillator implantation: a randomized trial

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.

Safety of continuous anticoagulation with dabigatran during implantation of cardiac rhythm devices

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.

Anticoagulation management in patients with mechanical heart valves having pacemaker or defibrillator insertion

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.

Meta-analysis of safety and efficacy of uninterrupted warfarin compared to heparin-based bridging therapy during implantation of cardiac rhythm devices

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.

Managing anticoagulation in patients receiving implantable cardiac devices

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 .

Meta-analysis of bleeding complications associated with cardiac rhythm device implantation

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.

Striking a balance between the risks and benefits of anticoagulation bridge therapy in patients with atrial fibrillation: clinical updates and remaining controversies

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.

Implantation of cardiac rhythm devices during concomitant anticoagulation or antiplatelet therapy

Cardiac rhythm devices are increasingly being utilized as the population ages and the incidence of chronic heart failure, bradyarrhythmias and the indications for pacing and prevention of sudden cardiac arrest expand. The number of patients receiving oral anticoagulants and dual antiplatelet therapy is similarly increasing. Implantation of cardiac rhythm devices during concomitant use of oral anticoagulants or antiplatelet regimens poses an increased risk of perioperative bleeding complications. Traditionally, heparin-based bridging protocols have been recommended for such patients to mitigate the bleeding risk while reducing the risk of thrombotic complications. Although the literature is limited, an appraisal of the literature reveals that bridging may not be the best strategy. We review the literature and propose strategies to promote successful perioperative outcomes, while reducing the risk of bleeding or thrombosis during the time of implantation for patients on chronic anticoagulation and antiplatelet therapies.

No increased bleeding events with continuation of oral anticoagulation therapy for patients undergoing cardiac device procedure

BACKGROUND

Switching warfarin for heparin has been a practice for managing periprocedural anticoagulation in high-risk patients undergoing device-related procedures. We sought to investigate whether continuation of warfarin sodium therapy without heparin bridging is safe and, when it is continued, the optimal international normalized ratio (INR) without increased bleeding risk at time of device-related procedure.

METHODS AND RESULTS

We retrospectively studied 766 consecutive patients taking warfarin long term who underwent device-related procedures. Patients were grouped by treatment: discontinued warfarin (-warfarin, n = 243), no interruption of warfarin (+warfarin, n = 324), and discontinued warfarin with heparin bridging (+heparin, n = 199). The study primary endpoint was systemic bleeding or formation of moderate or severe pocket hematoma within 30 days of the procedure. Thirty-one (4%) patients had bleeding events, including pocket hematoma in 29 patients. The bleeding events occurred more often for +heparin (7.0%) than -warfarin (2.1%) or +warfarin (3.7%, P = 0.029). For +warfarin group, INR of 2.0-2.5 at time of procedure did not increase bleeding risk compared with INR less than 1.5 (3.7% vs 3.4%; P = 0.72), but INR greater than 2.5 increased the bleeding risk (10.0% vs 3.4%; P = 0.029). Concomitant aspirin use with warfarin significantly increased bleeding risk than warfarin alone (5.6% vs 1.4%, P = 0.02). Median length of hospitalization was significantly shorter for +warfarin than +heparin (1 vs 6 days; P < 0.001).

CONCLUSION

Continuation of oral anticoagulation therapy with an INR level of <2.5 does not impose increased risk of bleeding for device-related procedures, although precaution is necessary to avoid supratherapeutic anticoagulation levels.

[Oral anticoagulation doesn't increase hemorrhagic risk in patients undergoing a cardiac pacemaker or defibrillator implantation]

OBJECTIVES

This study was designed to assess the hypothesis that the implantation or the replacement of a cardiac stimulator or defibrillator in patients receiving oral anticoagulants with an INR≥2 doesn't increase the hemorrhagic risk in comparison with patients for whom the treatment has been interrupted temporarily (INR<2) or with patients not receiving anticoagulants (control group).

PATIENTS AND RESULTS

We performed a retrospective chart review of bleeding complications in all patients undergoing pacemaker or ICD implantation or replacement between January 2007 and may 2009. In this cohort, 43 patients (10%) were implanted with an INR≥2 while 36 patients (8%) were implanted with an INR<2 and 352 patients (82%) didn't receive anticoagulants. No complication (0/36) has been observed in patients having an INR<2, while 3/43 (7%) complications have been observed in patients with an INR≥2 and 13/352 (3.7%) in patients in the control group (p=0.3093). Duration of the hospital stay was similar in the three groups: 6.2 days in patients with an INR<2, 6.8 days in the group with an INR≥2 and 6.2days in the control group (p=0.686).

CONCLUSION

Pacemaker and ICD implantation or replacement without withdrawing of oral anticoagulants and an INR≥2 was not associated with an increase of the hemorrhagic risk.

Risk of Hematoma Complications After Device Implant in the Clopidogrel Era

Background—

Device implant pocket hematoma is a recognized complication after permanent pacemaker (PM) and implantable cardioverter-defibrillator (ICD) implantation. Pocket hematoma is associated with local discomfort, an increased risk of infection, and may require surgical intervention or lead to lengthier hospital stays. The purpose of the study was to identify the clinical factors associated with hematoma formation after PM or ICD device implantation.

Methods and Results—

The subjects of this prospective observational study were 935 consecutive patients at Beaumont Hospital who underwent implantation of a PM or an ICD. Clinical characteristics and anticoagulant/antiplatelet drug use were recorded. A pocket hematoma was documented in 89 of 935 patients. Significant predictors of device pocket hematoma included ongoing clopidogrel therapy (18.3% on therapy, 10.5% recently discontinued, and 7.9% off therapy; P <0.001) and use of intravenous heparin (22.0% on therapy versus 8.2%; P <0.0001). Patients in whom clopidogrel was discontinued >4 days before device implantation had no hematoma. Hematomas occur more frequently in patients receiving ICDs than those receiving PMs. Device pocket hematoma was associated with an increased median length of hospital stay (4 days [interquartile range, 1 to 9] days with versus 2 days [ interquartile range, 1 to 6] days without hematoma; P =0.004) and increased late complications or surgical intervention.

Conclusions—

The use of clopidogrel or intravenous heparin significantly increased the risk of hematoma at the time of PM or ICD implantation. By withholding clopidogrel before surgery, the excess risk of bleeding complications may be reduced.

[Progress in cardiac pacing]

This review discusses the utility and current status of remote monitoring in patients with cardiac devices in Spain, the different anticoagulation strategies used during device implantation, the surgical replacement and maintenance of pacemakers and defibrillators, and the present and future importance of impedance sensors in cardiac pacing and heart failure management. Finally, there is a summary of the most relevant scientific articles published in the last year.

Perioperative management of anticoagulation during device implantation-the UK perspective

BACKGROUND

Increasing numbers of patients taking oral anticoagulation are presenting for device implantation. Cessation of anticoagulation in the perioperative period may expose patients to increased risk of thromboembolic events, while continuing anticoagulation may increase the risk of bleeding. There are few guidelines or randomized controlled trials to guide perioperative management.

METHODS

We carried out a questionnaire-based study of all cardiologists implanting devices in the United Kingdom to establish if there was consensus on management of anticoagulation in patients undergoing pacemaker implantation.

RESULTS

There is significant variation in management of these patients. Eighty-nine percent of doctors stop oral anticoagulation a mean 3.7 days prior to pacemaker implantation in patients with a mechanical mitral valve, with 94% using heparin to provide preoperative anticoagulation: 58% unfractionated heparin, 40% low molecular weight heparin. The maximum accepted international normalized ratio for implantation ranged from 1.4 to 3 (median 1.8). Postoperatively, 86% restart heparin after a mean 8.5 hours. Only 11% continue oral anticoagulation throughout the implantation period. There is a hierarchy of perceived embolic risk with doctors using progressively less anticoagulation in patients with prosthetic aortic valve, high-risk, and low-risk atrial fibrillation. In contrast, only 7% of implanters stop theinopyridines prior to device implantation in patients with a 2-month-old drug eluting stent.

CONCLUSION

Perioperative anticoagulation management of patients undergoing device procedures is currently performed with little consensus. This emphasizes the need for careful national and international audit of periprocedural anticoagulation management and its associated complications with a view to developing international consensus guidelines. (PACE 2010; 389-393).

[Hemorrhagic risk of different perioperative anticoagulation protocols in patients implanted with a cardiac pacemaker or defibrillator: retrospective analysis in patients implanted in a community hospital]

AIMS

Perioperative management of anticoagulation in patients referred for pacemaker or cardiac defibrillator implantation isn't consensual. Our objective was to evaluate, in a large cohort, hemorrhagic complications in patients having implantation or replacement of a cardiac pacemaker or defibrillator, and to assess perioperative anticoagulation effect on hemorrhagic risk.

METHODS AND RESULTS

A cohort of 461 consecutive patients having implantation or replacement of a cardiac pacemaker or defibrillator has been analyzed. Thirty patients (6,5%) had oral anticoagulants (OAC) switched to heparin/low-molecular-weight heparin, while 76 (16,5%) had their oral anticoagulation disrupted habitually for 48 hours. A total of six over 30 (20%) and two over 76 (2.6%) patients in the bridge and OAC, respectively experienced a pocket hematoma (bridge vs. OAC, p<0.05), while ten over 355 (2.8%) had a pocket hematoma in the control group (bridge vs. control p=0.006). Duration of the hospital stay was longer in the bridge group in comparison with OAC and control groups (9 vs. 7 vs. 6 days, respectively, p=0.006).

CONCLUSION

Oral anticoagulation bridging with heparin or low-molecular-weight heparin is associated with a higher risk of pocket hematoma and a longer duration of hospitalization, in comparison with a strategy allowing a temporary disruption of OAC adapted to the thromboembolic risk.

Implantation of cardiac rhythm devices without interruption of oral anticoagulation compared with perioperative bridging with low-molecular weight heparin

BACKGROUND

Increasing numbers of patients requiring arrhythmia device implantation are taking warfarin. The common practice of warfarin interruption and perioperative bridging with heparin is associated with a high rate of postoperative hemorrhagic complications. We assessed the safety of device implantation without interruption of warfarin therapy.

METHODS

Three patient groups were studied: Group 1 consisted of 117 consecutive patients on long-term warfarin therapy with significant risk of thromboembolism (atrial fibrillation with CHADS(2) score > or =2, mechanical heart valve, recent venous thromboembolism) who underwent arrhythmia device implantation without interruption of warfarin. Group 2 was 117 patients who served as age- and sex-matched controls matched to procedure type not taking warfarin. Group 3 consisted of 38 similar thromboembolic risk historical control patients who underwent interruption of warfarin therapy and bridging with dalteparin before and 24 hours after surgery. Active fixation leads were used by subclavian or axillary vein puncture, with septal fixation in the ventricle in 56% of patients. Hemorrhagic and thromboembolic complications were assessed at discharge and at 7 and 30 days after surgery.

RESULTS

During an 18-month period, 1,562 consecutive adult patients underwent heart rhythm device implantation or replacement. One hundred seventeen of the 447 patients on warfarin were considered high risk and remained on warfarin for their procedure. The mean international normalized ratio in group 1 patients was 2.2 +/- 0.4 (age 79 +/- 11 years, 73 male). Significant hematoma was noted in 9 patients (7.7%), and one required surgical revision (0.9%). Five group 2 patients (control) had significant hematomas (4.3%), none of which required revision (P = .41). In group 3, 9 patients developed significant hematomas (23.7%, P = .012), 3 of whom required reoperation (7.9%, P = .046). There were no deaths, thromboembolic events, cardiac tamponade, or hemothorax in any patient. The only risk factor for hematoma in the warfarin patients was the number of leads implanted.

CONCLUSIONS

Arrhythmia devices can be implanted safely in patients with high thromboembolic risk without interruption of warfarin. This strategy may be associated with reduced risk of significant pocket hematoma compared with dalteparin bridging.

Preparation for pacemaker or implantable cardiac defibrillator implants in patients with high risk of thrombo-embolic events: oral anticoagulation or bridging with intravenous heparin? A prospective randomized trial

AIMS

Current guidelines recommend stopping oral anticoagulation (OAC) and starting heparin infusion before implanting/replacing a pacemaker/implantable cardioverter-defibrillator (ICD) in patients with high risk for thrombo-embolic events. The aim of this study was to demonstrate that the maintenance of OAC during device implantation/replacement is as safe as bridging to intravenous heparin and shortens in-hospital stay.

METHODS AND RESULTS

A cohort of 101 consecutive patients with high risk for embolic events and indication for implant/replacement of a pacemaker/ICD were randomized to two anticoagulant strategies: bridging from OAC to heparin infusion (n = 51) vs. maintenance of OAC to reach an INR = 2 +/- 0.3 at the day of the procedure (n = 50). Haemorrhagic and thrombo-embolic complications were evaluated at discharge, 15 and 45 days after the procedure. A total of 4/51 patients (7.8%) from heparin group and 4/50 (8.0%) from the OAC group developed pocket haematoma following the implant (P = 1.00). One haematoma in each group required evacuation (1.9 vs. 2%, P = 1.00). No other haemorrhagic events or embolic complications developed during the follow-up. Duration of the hospital stay was longer in the heparin group [median of 5 (4-7) vs. 2 (1-4) days; P < 0.001].

CONCLUSION

Implant of devices maintaining OAC is as safe as bridging to heparin infusion and allows a significant reduction of in-hospital stay.