Pacemaker or defibrillator surgery without interruption of anticoagulation

Medical Clinics of North America-Periprocedural Antithrombotics: Prophylaxis and Interruption

Anticoagulation management in the surgical patient requires clinical expertise and careful attention. For patients already receiving anticoagulation for a defined indication (ie, stroke prevention for atrial fibrillation, treatment of venous thromboembolism (VTE), or presence of a mechanical heart valve), understanding how to manage these agents by weighing the risks of thromboembolic events and bleeding is paramount. Additionally, prevention of VTE in the surgical patient involves the identification of patient-specific and procedure-specific risk factors for both VTE and bleeding. With this information, as well as familiarity with the several antithrombotic options available, an appropriate prophylaxis strategy can be employed.

Cardiovascular Implantable Electronic Device Infections: A Contemporary Review

Infections associated with cardiac implantable electronic devices (CIEDs) are increasing and are a cause of significant morbidity and mortality. This article summarizes the latest updates with respect to the epidemiology, microbiology, and risk factors for CIED-related infections. It also covers important considerations regarding the diagnosis, management, and prevention of these infections. Newer technologies such as leadless pacemakers and subcutaneous implantable cardioverters and defibrillators are discussed.

Continuation versus Interruption of Oral Anticoagulation during TAVI

BACKGROUND

One third of patients undergoing transcatheter aortic-valve implantation (TAVI) have an indication for oral anticoagulation owing to concomitant diseases. Interruption of oral anticoagulation during TAVI may decrease the risk of bleeding, whereas continuation may decrease the risk of thromboembolism.

METHODS

We conducted an international, open-label, randomized, noninferiority trial involving patients who were receiving oral anticoagulants and were planning to undergo TAVI. Patients were randomly assigned in a 1:1 ratio to periprocedural continuation or interruption of oral anticoagulation. The primary outcome was a composite of death from cardiovascular causes, stroke from any cause, myocardial infarction, major vascular complications, or major bleeding within 30 days after TAVI.

RESULTS

A total of 858 patients were included in the modified intention-to-treat population: 431 were assigned to continuation and 427 to interruption of oral anticoagulation. A primary-outcome event occurred in 71 patients (16.5%) in the continuation group and in 63 (14.8%) in the interruption group (risk difference, 1.7 percentage points; 95% confidence interval [CI], -3.1 to 6.6; P = 0.18 for noninferiority). Thromboembolic events occurred in 38 patients (8.8%) in the continuation group and in 35 (8.2%) in the interruption group (risk difference, 0.6 percentage points; 95% CI, -3.1 to 4.4). Bleeding occurred in 134 patients (31.1%) in the continuation group and in 91 (21.3%) in the interruption group (risk difference, 9.8 percentage points; 95% CI, 3.9 to 15.6).

CONCLUSIONS

In patients undergoing TAVI with a concomitant indication for oral anticoagulation, periprocedural continuation was not noninferior to interruption of oral anticoagulation during TAVI with respect to the incidence of a composite of death from cardiovascular causes, stroke, myocardial infarction, major vascular complications, or major bleeding at 30 days. (Funded by the Netherlands Organization for Health Research and Development and the St. Antonius Research Fund; POPular PAUSE TAVI ClinicalTrials.gov number, NCT04437303.).

The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for the Mitigation of Complications of Neurostimulation

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.

Infective endocarditis

First described more than 350 years ago, infective endocarditis represents a global health concern characterised by infections affecting the native or prosthetic heart valves, the mural endocardium, a septal defect, or an indwelling cardiac device. Over recent decades, shifts in causation and epidemiology have been observed. Echocardiography remains pivotal in the diagnosis of infective endocarditis, with alternative imaging modalities gaining significance. Multidisciplinary management requiring expertise of cardiologists, cardiovascular surgeons, infectious disease specialists, microbiologists, radiologists and neurologists, is imperative. Current recommendations for clinical management often rely on observational studies, given the limited number of well conducted randomised controlled trials studying infective endocarditis due to the rarity of the disease. In this Seminar, we provide a comprehensive overview of optimal clinical practices in infective endocarditis, highlighting key aspects of pathophysiology, pathogens, diagnosis, management, prevention, and multidisciplinary approaches, providing updates on recent research findings and addressing remaining controversies in diagnostic accuracy, prevention strategies, and optimal treatment.

[Treatment with cardiac electronic implantable devices]

Cardiac device therapy provides not only treatment options for bradyarrhythmia but also advanced treatment for heart failure and preventive measures against sudden cardiac death. In heart failure treatment it enables synergistic reverse remodelling and reduces pharmacological side effects. Cardiac resynchronization therapy (CRT) has revolutionized the treatment of reduced left ventricular ejection fraction (LVEF) and left bundle branch block by decreasing the mortality and morbidity with improvement of the quality of life and resilience. Conduction system pacing (CSP) as an alternative method of physiological stimulation can improve heart function and reduce the risk of pacemaker-induced cardiomyopathy. Leadless pacers and subcutaneous/extravascular defibrillators offer less invasive options with lower complication rates. The prevention of infections through preoperative and postoperative strategies enhances the safety of these therapies.

Impact of omitting the intravenous heparin bolus on outcomes of leadless pacemaker implantation

BACKGROUND

Early guidance recommended a bolus of intravenous heparin at the beginning of leadless pacemaker (LP) implantation procedures. However, due to concern about bleeding complications, more recent practice has tended toward omitting the bolus and only running a continuous heparin infusion through the introducer sheath. The impact of omitting the heparin bolus on procedural outcomes is not clear.

METHODS

We reviewed all Medtronic Micra LP implants at our institution from 9/2014 to 9/2022. The decision to bolus with heparin was at operator discretion.

RESULTS

Among 621 LP implants, 326 received an intravenous heparin bolus, 243 did not, and 52 patients were excluded because heparin bolus status could not be confirmed. There was a trend toward more frequent omission of the heparin bolus with more recent implants. Median follow-up after LP implant was 14.3 (interquartile range [IQR]: 8.4-27.9) months. There was no difference between heparin bolus and no bolus groups in the number of device deployments/recaptures (1.42 ± 0.81 vs. 1.31 ± 0.66, p = .15). Implant-related adverse events were also similar between heparin bolus and no bolus groups: access-site hematoma requiring intervention (7 vs. 5, p = .99), pseudoaneurysm (1 vs. 1, p = .99), cardiac perforation (1 vs. 1, p = .99), intraprocedural device thrombus formation (2 vs. 4, p = .41), 30-day rehospitalization (21 vs. 15, p = .98), and 30-day all-cause mortality (16 vs. 14, p = .70). There was one additional nonfatal cardiac perforation in a patient who was excluded due to unknown heparin bolus status. Regarding device electrical parameters between heparin bolus and no bolus groups, there were no significant differences at the time of implant: pacing capture threshold 0.5 ± 0.4 vs. 0.5 ± 0.3, p = .10; pacing impedance 739.9 ± 226.4 vs. 719.1 ± 215.4, p = .52; R wave sensing 11.7 ± 5.7 vs. 12.0 ± 5.4, p = .34). Long-term device performance was also similar between groups.

CONCLUSION

Omission of the systemic heparin bolus at the time of LP implantation appears safe in appropriately selected patients. Heparin bolus may still be considered in long cases requiring multiple device deployments or in patients at high risk for thrombotic complications.

Risk of infections related to endovascular catheters and cardiac implantable devices in hemodialysis patients

Patients requiring dialysis are extremely vulnerable to infectious diseases. The high burden of comorbidities and weakened immune system due to uremia and previous immunosuppressive therapy expose the patient on dialysis to more infectious events than the general population. The infectious risk is further increased by the presence of endovascular catheters and implantable cardiologic devices. The former is generally placed as urgent vascular access for dialysis and in subjects requiring hemodialysis treatments without autogenous arteriovenous fistula. The high frequency of cardiovascular events also increases the likelihood of implanting indwelling implantable cardiac devices (CIED) such as pacemakers (PMs) and defibrillators (ICDs). The simultaneous presence of CVC and CIED yields an increased risk of developing severe prosthetic device-associated bloodstream infections often progressing to septicemia. Although, antibiotic therapy is the mainstay of prosthetic device-related infections, antibiotic resistance of biofilm-residing bacteria reduces the choice of infection eradication. In these cases, the resolution of the infection process relies on the removal of the prosthetic device. Compared to CVC removal, the extraction of leads is a more complex procedure and poses an increased risk of vessel tearing. As a result, the prevention of prosthetic device-related infection is of utmost importance in hemodialysis (HD) patients and relies principally on avoiding CVC as vascular access for HD and placement of a new class of wireless implantable medical devices. When the combination of CVC and CIED is inevitable, prevention of infection, mainly due translocation of skin bacteria, should be a mandatory priority for healthcare workers.

[Perioperative management for cardiovascular implantable electronic devices]

Cardiovascular implantable electronic devices (CIED) are an important part of modern cardiology and careful perioperative planning of these procedures is necessary. All information relevant to the indication, the procedure, and the education of the patient must be available prior to surgery. This provides the basis for appropriate device selection. Preoperative antibiotic prophylaxis and perioperative anticoagulation management are essential to prevent infection. After surgery, postoperative monitoring, telemetric control, and device-based diagnostics are required before discharge. These processes need to be adapted to the increasing trend towards outpatient care. This review summarises perioperative management based on practical considerations.

Trends in the 30-year span of noninfectious cardiovascular implantable electronic device complications in Olmsted County

Background

Cardiac implantable electronic devices (CIEDs), such as permanent pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices, alleviate morbidity and mortality in various diseases. There is a paucity of real-world data on CIED complications and trends.

Objectives

We sought to describe trends in noninfectious CIED complications over the past 3 decades in Olmsted County.

Methods

The Rochester Epidemiology Project is a medical records linkage system comprising records of over 500,000 residents of Olmsted County from 1966 to present. CIED implantations between 1988 and 2018 were determined. Trends in noninfectious complications within 30 days of implantation were analyzed.

Results

A total of 157 (6.2%) of 2536 patients who received CIED experienced device complications. A total of 2.7% of the implants had major complications requiring intervention. Lead dislodgement was the most common (2.8%), followed by hematoma (1.7%). Complications went up from 1988 to 2005, and then showed a downtrend until 2018, driven by a decline in hematomas in the last decade (P < .01). Those with complications were more likely to have prosthetic valves. Obesity appeared to have a protective effect in a multivariate regression model. The mean Charlson comorbidity index has trended up over the 30 years.

Conclusion

Our study describes a real-world trend of CIED complications over 3 decades. Lead dislodgements and hematomas were the most common complications. Complications have declined over the last decade due to safer practices and a better understanding of anticoagulant management.

Do Implantable Cardioverter-Defibrillators Prevent Sudden Cardiac Death in End-Stage Renal Disease Patients on Dialysis?

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.

Update on Cardiovascular Implantable Electronic Device Infections and Their Prevention, Diagnosis, and Management: A Scientific Statement From the American Heart Association: Endorsed by the International Society for Cardiovascular Infectious Diseases

The American Heart Association sponsored the first iteration of a scientific statement that addressed all aspects of cardiovascular implantable electronic device infection in 2010. Major advances in the prevention, diagnosis, and management of these infections have occurred since then, necessitating a scientific statement update. An 11-member writing group was identified and included recognized experts in cardiology and infectious diseases, with a career focus on cardiovascular infections. The group initially met in October 2022 to develop a scientific statement that was drafted with front-line clinicians in mind and focused on providing updated clinical information to enhance outcomes of patients with cardiovascular implantable electronic device infection. The current scientific statement highlights recent advances in prevention, diagnosis, and management, and how they may be incorporated in the complex care of patients with cardiovascular implantable electronic device infection.

Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review

Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.

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

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.

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

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.

DOACs vs Vitamin K Antagonists During Cardiac Rhythm Device Surgery: A Multicenter Propensity-Matched Study

BACKGROUND

There is a paucity of data comparing vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs) at the time of cardiac implantable electronic device (CIED) surgery. Furthermore, the best management of DOACs (interruption vs continuation) is yet to be determined.

OBJECTIVES

This study aimed to compare the incidence of device-related bleeds and thrombotic events based on anticoagulant type (DOAC vs VKA) and regimen (interrupted vs uninterrupted).

METHODS

This was an observational multicenter study. We included patients on chronic oral anticoagulation undergoing CIED surgery. Patients were matched using propensity scoring.

RESULTS

We included 1,975 patients (age 73.8 ± 12.4 years). Among 1,326 patients on DOAC, this was interrupted presurgery in 78.2% (n = 1,039) and continued in 21.8% (n = 287). There were 649 patients on continued VKA. The matched population included 861 patients. The rate of any major bleeding was higher with continued DOAC (5.2%) compared to interrupted DOAC (1.7%) and continued VKA (2.1%) (P = 0.03). The rate of perioperative thromboembolism was 1.4% with interrupted DOAC, whereas no thromboembolic events occurred with DOAC or VKA continuation (P = 0.04). The use of dual antiplatelet therapy, DOAC continuation, and male sex were independent predictors of major bleeding on a multivariable analysis.

CONCLUSIONS

In this large real-world cohort, a continued DOAC strategy was associated with a higher bleeding risk compared to DOAC interruption or VKA continuation in patients undergoing CIED surgery. However, DOAC interruption was associated with increased thromboembolic risk. Concomitant dual antiplatelet therapy should be avoided whenever clinically possible. A bespoke approach is necessary, with a strategy of minimal DOAC interruption likely to represent the best compromise.

A cross-sectional study of appropriateness evaluation of anticoagulation therapy for inpatients with nonvalvular atrial fibrillation

Background: Oral anticoagulants (OACs) are essential for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). However, the appropriateness of anticoagulation treatment in locally practice remains unclear. This study evaluated compliance with anticoagulation therapy concerning the guidelines and drug labels in patients with NVAF. Methods: Hospitalized patients diagnosed with NVAF between 1 November 2020, and 31 December 2021, were retrospectively enrolled. The appropriateness of anticoagulation regimens at discharge was evaluated based on a flowchart designed according to atrial fibrillation (AF) guidelines and medication labels. Furthermore, we explored factors potentially influencing the "no-use of OACs" using binary logistic regression and verified anticoagulation-related issues through a physician questionnaire. Results: A total of 536 patients were enrolled in this study, including 254 patients (47.4%) with inappropriate anticoagulation regimens. 112 patients (20.9%) were categorized as "underdosing-use of OACs," 134 (25%) who needed anticoagulation therapy were "no-use of OACs" and eight (1.5%) were "over-use of OACs." The results of a binary logistic regression analysis showed that paroxysmal AF (odds ratio [OR], 7.74; 95% confidence interval [CI], 4.57-13.10), increased blood creatinine levels (OR, 1.88; 95% CI, 1.11-3.16), hospitalized pacemaker implantation (OR, 6.76; 95% CI, 2.67-17.11), percutaneous coronary intervention (OR, 3.35; 95% CI, 1.44-7.80), and an increased HAS-BLED score (OR, 1.62; 95% CI, 1.11-2.35) were associated with "no-use of OACs" in patients with NVAF who had indications for anticoagulation therapy. Conclusion: For patients with NVAF with severe renal dysfunction and paroxysmal AF, anticoagulation therapy was inadequate. The underdosing-use of OACs in patients with NVAF was frequently observed. We recommend an anticoagulation management team to tailor anticoagulation regimens to suit each patient's needs.

Translation of Tools and Techniques from the Adult Electrophysiology World to Pediatric Cardiac Implantable Electronic Devices

This article reviews various opportunities to translate established and novel tools and techniques used in adult electrophysiology to pediatrics and the adult congenital heart disease population. There is a specific focus on preoperative management of special population, implantation techniques, and postoperative programming of devices.

Lead Management in Patients with Congenital Heart Disease

Pediatric patients with congenital heart disease present unique challenges when it comes to cardiac implantable electronic devices. Pacing strategy is often determined by patient size/weight and operator experience. Anatomic considerations, including residual shunts, anatomic obstructions and barriers, and abnormalities in the native conduction system, will affect the type of CIED implanted. Given the young age of patients, it is important to have an "eye on the future" when making pacemaker/defibrillator decisions, as one can expect several generator changes, lead revisions, and potential lead extractions during their lifetime.

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

Peri-Procedural Management of Direct-Acting Oral Anticoagulants (DOACs) in Transcatheter Miniaturized Leadless Pacemaker Implantation

INTRODUCTION

Data on peri-operative management of direct-acting oral anticoagulants (DOACs) during transcatheter pacing leadless system (TPS) implantations remain limited. This study aimed to evaluate a standardized DOAC management regime consisting of interruption of a single dose prior to implantation and reinitiation within 6-24 h; also, patient clinical characteristics associated with this approach were identified.

METHOD

Consecutive patients undergoing standard TPS implantation procedures from two Swiss tertiary centers were included. DOAC peri-operative management included the standardized approach (Group 1A) or other approaches (Group 1B).

RESULTS

Three hundred and ninety-two pts (mean age 81.4 ± 7.3 years, 66.3% male, left ventricular ejection fraction 55.5 ± 9.6%) underwent TPS implantation. Two hundred and eighty-two pts (71.9%) were under anticoagulation therapy; 192 pts were treated with DOAC; 90 pts were under vitamin-K antagonist. Patients treated with DOAC less often had structural heart disease, diabetes mellitus, and advanced renal failure. The rate of major peri-procedural complications did not differ between groups 1A (n = 115) and 1B (n = 77) (2.6% and 3.8%, p = 0.685). Compared to 1B, 1A patients were implanted with TPS for slow ventricular rate atrial fibrillation (AF) (p = 0.002), in a better overall clinical status, and implanted electively (<0.001).

CONCLUSIONS

Standardized peri-procedural DOAC management was more often implemented for elective TPS procedures and did not seem to increase bleeding or thromboembolic adverse events.

Perioperative Management of Anticoagulant and Antiplatelet Therapy

Anticoagulant and Antiplatelet Drug ManagementManagement of patients on an anticoagulant or antiplatelet drug who require surgery or an invasive procedure is a common clinical problem. Douketis and Spyropoulos provide an evidence-based but practical approach to managing anticoagulants and antiplatelet drugs in the perioperative setting.

Safety of Continuing Anticoagulation Prior to Cardiac Catheterization in Pediatric Patients: A Los Angeles Center Experience

This is the first report specifically describing outcomes of pediatric patients who underwent cardiac catheterization while on uninterrupted anticoagulation. One hundred forty-four cardiac catheterizations were identified that met inclusion criteria at our institution from 11/2014 to 10/2019. The median age and weight of the patients were 6.3 [0.01-20.9] years and 19.3 [2.1-172.5] kg, respectively. Seventy-eight (54%) catheterizations involved inpatients. The most common cardiac diagnoses among the cohort were single ventricle (n = 41), conotruncal defects (n = 37), and structurally normal heart (n = 16). The most common indications for anticoagulation were arterial/venous thrombus (n = 45), Fontan physiology (n = 32), and mechanical valve thrombus prophylaxis (n = 27). The anticoagulation medications used were warfarin (n = 57), heparin (n = 52), enoxaparin (n = 25), fondaparinux (n = 5), rivaroxaban (n = 2), and both heparin and warfarin (n = 3). Interventions were performed in 96 cases (67%). The median length of the procedure was 122.5 [15-760] minutes, and the median time to achieve hemostasis was 18.0 [range: 5-76, IQR: 13-25] minutes. Adverse events were present in 11 cases (7.6%), and of those only 2 cases (1.4%) were bleeding-related complications. Our single-center data suggest that performing cardiac catheterization on pediatric patients while on uninterrupted anticoagulation is safe and does not substantially increase the risk of bleeding complications based on a cohort of patients that varied in age, size, diagnosis, medical complexity, and type of intervention performed. Patients on warfarin therapy for a mechanical valve are most likely to benefit from this practice, as the ability to continue warfarin therapy avoids the need for bridging and other interruption-related complications.

Impact of peri-procedural management of direct oral anticoagulants on pocket haematoma after cardiac electronic device implantation: the StimAOD multicentre prospective study

AIMS

The study aims to investigate the impact of direct oral anticoagulant (DOAC) management on the incidence of pocket haematoma in patients undergoing pacemaker or implantable cardioverter-defibrillator implantation.

METHODS AND RESULTS

All consecutive patients receiving DOAC and undergoing cardiac electronic device implantation were included in a large multicentre prospective observational study (NCT03879473). The primary endpoint was clinically relevant haematoma within 30 days after implantation. Overall, 789 patients were enrolled [median age 80 (IQR 72-85) years old, 36.4% women, median CHA2DS2-VASc score 4 (IQR 0-8)], of which 632 (80.1%) received a pacemaker implantation. Antiplatelet therapy was combined with DOAC in 146 patients (18.5%). Direct oral anticoagulants (DOACs) were interrupted 52 (IQR 37-62) h before the procedure and resumed 31 (IQR 21-47) h later. Ninety-six percent of the patients had at least 12 h DOAC interruption before the procedure, and 78% had at least 12 h DOAC interruption after the procedure. Overall, anticoagulation was interrupted for 72 (IQR 48-96) h. Pre- or post-procedural heparin bridging was used in 8.2% and 3.9%, respectively. Timing of DOAC interruption of resumption was not associated with clinically relevant haematoma. Clinically relevant haematoma occurred in 26 patients (3.3%), and thromboembolic events occurred in 5 patients (0.6%).

CONCLUSION

In this large real-life registry where most patients had DOAC interruption, clinically relevant haematoma was rare. Despite DOAC interruption and high CHA2DS2-VASc score, thromboembolic events occurred seldomly, highlighting that bleeding exceeds thromboembolic risk in this peri-procedural period. Future research is needed to identify risk factors for clinically relevant haematoma and meaningfully guide clinicians in optimizing DOAC management.

Trends in the 30-year span of Noninfectious Cardiovascular Implantable Electronic Device Complications in Olmsted County

Background

Cardiovascular implantable electronic devices (CIEDs) such as permanent pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices alleviate morbidity and mortality in various diseases. There is a paucity of real-world data on CIED complications and trends.

Objectives

Describe trends in noninfectious CIED complications over the past three decades in Olmsted County.

Methods

The Rochester Epidemiology Project is a medical records linkage system comprising records of over 500,000 residents of Olmsted County from 1966-current. CIED implants between 1988-2018 were determined. Trends in noninfectious complications within 30 days of implant were analyzed.

Results

175 out of 2536 (6.9%) patients who received CIED experienced device complications. 3.8% of the implants had major complications requiring intervention. Lead dislodgement was the most common (2.9%), followed by hematoma (2.1%). Complications went up from 1988 to 2005, then showed a downtrend until 2018, driven by a decline in hematomas in the last decade (p<0.01). Those with complications were more likely to have prosthetic valves. Obesity appeared to have a protective effect in a multivariate regression model. The mean Charlson comorbidity score has trended up over the 30 years.

Conclusions

Our study describes a real-world trend of CIED complications over three decades. Lead dislodgements and hematomas were the most common complications. Complications have declined over the last decade due to safer practices and a better understanding of anticoagulant management.

A Randomized Trial of Lenient Versus Strict Arm Instruction Post Cardiac Device Surgery (LENIENT)

BACKGROUND

Arm restriction after cardiac implantable electronic device (CIED) placement is common practice despite minimal supporting evidence. Patients receive a range of restriction recommendations of variable durations with the goal of reducing complications such as wound dehiscence, infection, lead dislodgement, or hematoma formation. These movement limitations can lead to emotional stress and anxiety, complications such as frozen shoulder, and upper extremity venous thrombosis due to immobilization. There are no published clinical trials assessing the benefits and risks of arm restrictions post-CIED implant.

OBJECTIVES

The randomized trial of lenient vs strict arm and activity instruction post-CIED surgery (LENIENT trial; NCT04915261) is a single center nonblinded randomized prospective study designed to evaluate lenient compared to restrictive post-CIED care instructions. We hypothesize that there will be no significant difference in complications between the arms.

METHODS/DESIGN

All patients receiving a de novo CIED or those with upgrades and revisions requiring a new lead implant will be enrolled. Subjects are enrolled in a nonblinded randomized prospective trial with 6 randomly assigned 8-month periods, during which either a lenient or restrictive postoperative activity instructions will be given to all patients. Postoperative instructions are given at the time of discharge and further reinforced by recurrent interactive voice recognition (IVR) phone calls, text messages and emails. The requirement for individual consent has been waived. The primary end point is a composite of (1) lead dislodgement, (2) frozen shoulder, (3) upper extremity venous thrombosis, (4) clinically significant hematoma, and (5) infection occurring within 52 weeks of index surgery. The study is a noninferiority trial with a sample size of 1,250 per group.

DISCUSSION

This is the first large randomized clinical trial designed to establish an evidence-based postoperative standard of care for patients undergoing CIED implantation. This will improve the quality of care provided to patients and help guide implanting physicians providing postoperative care instructions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04915261.

Continued non-vitamin K antagonist oral anticoagulants versus vitamin K antagonists during transcatheter aortic valve implantation

BACKGROUND

One-third of patients undergoing transcatheter aortic valve implantation (TAVI) have an indication for long-term oral anticoagulation (OAC).

AIMS

We aimed to investigate whether continued non-vitamin K antagonist oral anticoagulant (NOAC) therapy compared with continued vitamin K antagonist (VKA) therapy during TAVI is equally safe and effective.  Methods: Consecutive patients on OAC with either NOAC or VKA undergoing transfemoral TAVI at five European centres were enrolled. The primary outcome measure was a composite of major/life-threatening bleeding, stroke, and all-cause mortality at 30 days.

RESULTS

In total, 584 patients underwent TAVI under continued OAC with 294 (50.3%) patients receiving VKA and 290 (49.7%) patients receiving NOAC. At 30 days, the composite primary outcome had occurred in 51 (17.3%) versus 36 (12.4%) patients with continued VKA and with continued NOAC, respectively (odds ratio [OR] 0.68, 95% confidence interval [CI]: 0.43-1.07; p=0.092). Rates of major/life-threatening bleeding (OR 0.87, 95% CI: 0.52-1.47; p=0.606) and stroke (OR 1.02, 95% CI: 0.29-3.59; p=0.974) were not different between groups. In a multivariate Cox regression analysis, continued NOAC, compared with continued VKA, was associated with a lower risk for all-cause 1-year mortality (hazard ratio [HR] 0.61, 95% CI: 0.37-0.98; p=0.043). The analysis of the propensity score-matched cohort revealed similar results.

CONCLUSIONS

Continued NOAC compared with continued VKA during TAVI led to comparable outcomes with regard to the composite outcome measure indicating that continued OAC with both drugs is feasible. These hypothesis-generating results need to be confirmed by a dedicated randomised controlled trial.

Iatrogenic Strokes and Covert Brain Infarcts After Percutaneous Cardiac Procedures: An Update

Millions of cardiac procedures are performed worldwide each year, making the potential complication of periprocedural iatrogenic stroke an important concern. These strokes can occur intraoperatively or within 30 days of a procedure and can be categorised as either overt or covert, occurring without obvious acute neurologic symptoms. Understanding the prevalence, risk factors, and strategies for preventing overt and covert strokes associated with cardiac procedures is imperative for reducing periprocedural morbidity and mortality. In this narrative review, we focus on the impacts of perioperative ischemic strokes for several of the most common interventional cardiac procedures, their relevance from a neurologic standpoint, and future directions for the care and research on perioperative strokes. Depending on the percutaneous procedure, the rates of periprocedural overt strokes can range from as little as 0.01% to as high as 2.9%. Meanwhile, covert brain infarctions (CBIs) occur much more frequently, with rates for different procedures ranging from 10%-84%. Risk factors include previous stroke, atherosclerotic disease, carotid stenosis, female sex, and African race, as well as other patient- and procedure-level factors. While the impact of covert brain infarctions is still a developing field, overt strokes for cardiac procedures lead to longer stays in hospital and increased costs. Potential preventative measures include screening and vascular risk factor control, premedicating, and procedural considerations such as the use of cerebral embolic protection devices. In addition, emerging treatments from the neurologic field, including neuroprotective drugs and remote ischemic conditioning, present promising avenues for preventing these strokes and merit investigation in cardiac procedures.

Pocket histology at cardiac implantable electronic device replacement: What's new?

BACKGROUND

Repeated procedures involving the cardiac implantable electronic device (CIED) pocket increase the infection risk, and the extent of pocket adhesions may prolong the procedure time. Few data on pocket histology at the time of CIED replacement are available.

OBJECTIVE

The purpose of this study was to describe CIED pocket histology in a cohort of patients undergoing CIED replacement or upgrade.

METHODS

All consecutive patients undergoing CIED replacement or upgrade at our center between November 2019 and May 2020 were enrolled. Subclinical pocket infection was ruled out by physical inspection and laboratory parameters before the procedure. Pocket tissue specimens from the anterior and posterior pockets were obtained intraoperatively. A systematic histological analysis of capsular thickness, fibrous connective tissue, neovascularization, inflammation, and calcifications was performed.

RESULTS

Thirty patients (6 women, 20%) were enrolled. The mean capsular thickness was 0.8 ± 0.3 mm in the anterior wall and 1.1 ± 0.4 mm in the posterior wall. Subcapsular fibrosis was mild and multifocal in the anterior wall and moderate and focal in the posterior wall. Neovascularization was focal in most cases, and vessel remodeling mainly involved the tunica media. Chronic inflammation was usually mild and nongranulomatous, and in a quarter of cases, subacute exudative fibrous inflammation was detected in the posterior pocket wall.

CONCLUSION

The CIED pocket is a histopathologically dynamic environment, given the coexistence of both a subacute foreign body response and fibrous tissue growth, implying continuous remodeling due to an injury-repair mechanism. Strategies to interact with foreign body response might minimize inflammatory pocket activity, especially device encapsulation by tight fibrous tissue, and possibly complications related to repeated CIED procedures.

Periprocedural anticoagulation therapy in patients undergoing micra leadless pacemaker implantation

Over the past decade, there has been significant improvement in the treatment cardiac diseases and symptomatic bradyarrhythmias with the development of leadless pacemaker systems. The Micra transcatheter pacemaker system has been shown to mitigate a lot of the complications associated with traditional pacing systems, which are notably skin pocket and lead-related complications. Numerous studies have shown the low complication rates associated with Micra procedure; however, there have been no specific guidelines or recommendations surrounding periprocedural anticoagulant therapy. This is important because a significant percentage of patients requiring pacemaker therapy have an indication for anticoagulation therapy as well. Multiple studies have shown the safety of uninterrupted anticoagulation during Micra implant, however, there is insufficient high-quality data to recommend periprocedural systemic use of anticoagulation. In this paper, we review the available data surrounding anticoagulation therapy in patients undergoing Micra implantation and the potential bleeding risks associated with this procedure.

Perioperative Management of Patients Receiving Antithrombotic Therapy in Schemes and Algorithms

Currently, antithrombotic therapy is the basis of the pathogenetic treatment of many cardiovascular diseases, such as coronary heart disease, stroke, peripheral vascular disease, as well as mechanical heart valves, heart rhythm disturbances, venous thromboembolism. At the same time, chronic use of antiplatelet and/or anticoagulant drugs is a complicating factor in invasive and surgical procedures, as it increases the risk of bleeding. In this regard, a fundamentally important and complex question arises: how to minimize the risk of periprocedural bleeding without exposing the patient to an increased risk of ischemic and thromboembolic complications? Perioperative management of patients who take antithrombotic drugs for a long time is a complex problem that depends on many factors - the risk of surgery, anesthesia, cardiovascular risks, and the urgency of surgery. Each clinical situation should be assessed individually, collegially, with the participation of surgeons, anesthesiologists, and therapists. The introduction of a checklist into clinical practice for each planned surgical patient will allow us to calculate the individual risk of bleeding and thromboembolic complications, and provide an optimal preventive strategy for perioperative management of the patient. The algorithms and schemes presented in the article for the perioperative management of patients with non-cardiac interventions are aimed at standardizing the management of patients before non-cardiac surgical interventions, which will reduce hemorrhagic risks in the presence of the necessary antithrombotic therapy.

Anesthetic Considerations in the Electrophysiology Laboratory: A Comprehensive Review

Catheter ablation procedures for arrhythmias or implantation and/or extraction of cardiac pacemakers can present many clinical challenges. It is imperative that there is clear communication and understanding between the anesthesiologist and electrophysiologist during the perioperative period regarding the mode of ventilation, hemodynamic considerations, and various procedural complications. This article provides a comprehensive narrative review of the anesthetic techniques and considerations for catheter ablation procedures, ventilatory modes using techniques such as high-frequency jet ventilation, and strategies such as esophageal deviation and luminal temperature monitoring to decrease the risk of esophageal injury during catheter ablation. Various hemodynamic considerations, such as the intraprocedural triaging of cardiac tamponade and fluid administration during catheter ablation, also are discussed. Finally, this review briefly highlights the early research findings on pulse-field ablation, a new and evolving ablation modality.

Anticoagulation for Patients Undergoing Implantation of a Cardiac Implantable Electronic Device

AIMS/BACKGROUND

The number of cardiac devices implanted increases year on year, as does the complexity of the patients being managed. A large proportion of this patient group have an indication for anticoagulation, and this raises challenges around the perioperative management of these agents.

METHOD

A quality improvement project was conducted to review current practice, understand local experience and improve patient care.

RESULTS

Following the initial review, local guidelines were updated, the postoperative anticoagulation decision escalated to the responsible clinician and a clearer pathway for communicating the decision created.

CONCLUSIONS

The implemented changes have shown an overall improvement in junior doctor feedback and also clinical documentation in the electronic patient records.

Saner F, Stark K, Mayerle J, M. Lange C. Platelet Aggregation Inhibitors and Anticoagulants in Gastroenterological and Visceral Surgical Procedures

BACKGROUND

The proper management of patients being treated with platelet aggregation inhibitors or anticoagulant drugs is a common clinical problem for both elective and emergency procedures in gastroenterology and visceral surgery. The essential matters that must be kept in mind in this situation are the hemorrhagic risk of the procedure, the indication for anticoagulation, and the pharmacology of anticoagulant drugs and platelet aggregation inhibitors.

METHODS

This review is based on publications retrieved by a selective search in PubMed and on the guidelines of the relevant specialist societies.

RESULTS

Nearly all procedures in gastroenterology and visceral surgery can be performed under monotherapy with acetyl - salicylic acid. Other platelet aggregation inhibitors, such as clopidogrel or prasugrel, or anticoagulant drugs generally do not need to paused before diagnostic endoscopic procedures with a low risk of bleeding (<1.5%), but they must be paused before procedures in gastroenterology and visceral surgery where the risk of bleeding is high (≥ 1.5%). Bridging with heparin is reserved for patients with a very high risk of thromboembolism ( ≥ 5%).

CONCLUSION

Knowledge of the current recommendations on the management of anticoagulants before gastroenterological and visceral surgical procedures gives the clinician a well-founded means of dealing with this complex and common clinical situation.

Perioperative Management of Vitamin K Antagonists and Direct Oral Anticoagulants: A Systematic Review and Meta-analysis

BACKGROUND

The management of patients who are receiving chronic oral anticoagulation therapy and require an elective surgery or an invasive procedure is a common clinical scenario.

RESAERCH QUESTION

What is the best available evidence to support the development of American College of Chest Physicians guidelines on the perioperative management of patients who are receiving long-term vitamin K agonist (VKA) or direct oral anticoagulant (DOAC) and require elective surgery or procedures?

STUDY DESIGH AND METHODS

A literature search including multiple databases from database inception through July 16, 2020, was performed. Meta-analyses were conducted when appropriate.

RESULTS

In patients receiving VKA (warfarin) undergoing elective noncardiac surgery, shorter (< 5 days) VKA interruption is associated with an increased risk of major bleeding. In patients who required VKA interruption, heparin bridging (mostly with low-molecular-weight heparin [LMWH]) was associated with a statistically significant increased risk of major bleed (relative risk [RR], 9.1; 95% CI, 1.62-51.3), representing a very low certainty of evidence (COE). Compared with DOAC interruption 1 to 4 days before surgery, continuing DOACs was not associated with a statistically significant difference in the risk of bleeding, representing a very low COE. Continuing dabigatran was associated with a statistically significant increased risk of thromboembolism (RR, 2.2; 95% CI, 1.3-3.8), representing a low COE. In patients who needed DOAC interruption, bridging with LMWH was associated a with statistically significant increased risk of minor bleeding compared with no bridging (RR, 1.7; 95% CI, 1.13-2.7), representing a low COE.

INTERPRETATION

The certainty in the evidence supporting the perioperative management of anticoagulants remains limited. No high-quality evidence exists to support the practice of heparin bridging during the interruption of VKA or DOAC therapy for an elective surgery or procedure or for the practice of interrupting VKA therapy for minor procedures, including cardiac device implantation, or continuation of a DOAC vs short-term interruption of a DOAC (1-4 days) in the perioperative period.

Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

METHODS

Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

RESULTS

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

CONCLUSIONS

Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Risk factors for cardiac implantable electronic device infections: a nationwide Danish study

AIMS

Cardiac implantable electronic device (CIED) infection is a severe complication to modern management of cardiac arrhythmias. The CIED type and the type of surgery are recognized as risk factors for CIED infections, but knowledge of patient-related risk factors is scarce. This study aimed to identify lifelong patient-related risk factors for CIED infections.

METHODS AND RESULTS

Consecutive Danish patients undergoing a CIED implantation or reoperation between January 1996 and April 2018 were included. The cohort consisted of 84 429 patients undergoing 108 494 CIED surgeries with a combined follow-up of 458 257 CIED-years. A total of 1556 CIED explantations were classified as either pocket (n = 1022) or systemic CIED infection (n = 534). Data were cross-linked with records from the Danish National Patient Registry and the Danish National Prescription Registry. Using multiple-record and multiple-event per subject proportional hazard analysis, specific patient-related risk factors were identified but with several variations amongst the subtypes of CIED infection. CIED reoperations were associated with the highest risk of pocket CIED infection but also CIED type, young age, and prior valvular surgery [hazard ratio (HR): 1.62, 95% confidence interval (CI): 1.29-2.04]. Severe renal insufficiency/dialysis (HR: 2.40, 95% CI: 1.65-3.49), dermatitis (HR: 2.80, 95% CI: 1.92-4.05), and prior valvular surgery (HR: 2.09, 95% CI: 1.59-2.75) were associated with the highest risk of systemic CIED infections. Congestive heart failure, ischaemic heart disease, malignancy, chronic obstructive pulmonary disease, and temporary pacing were not significant at multivariate analysis.

CONCLUSION

Specific comorbidities and surgical procedures were associated with a higher risk of CIED infections but with variations amongst pocket and systemic CIED infection. Pocket CIED infections were associated with CIED reoperations, young age and more complex type of CIED, whereas systemic CIED infections were associated with risk factors predisposing to bacteraemia.

Device-related complications in subcutaneous versus transvenous ICD: a secondary analysis of the PRAETORIAN trial

BACKGROUND

The subcutaneous implantable cardioverter-defibrillator (S-ICD) is developed to overcome lead-related complications and systemic infections, inherent to transvenous ICD (TV-ICD) therapy. The PRAETORIAN trial demonstrated that the S-ICD is non-inferior to the TV-ICD with regard to the combined primary endpoint of inappropriate shocks and complications. This prespecified secondary analysis evaluates all complications in the PRAETORIAN trial.

METHODS AND RESULTS

The PRAETORIAN trial is an international, multicentre, randomized trial in which 849 patients with an indication for ICD therapy were randomized to receive an S- ICD (N = 426) or TV-ICD (N = 423) and followed for a median of 49 months. Endpoints were device-related complications, lead-related complications, systemic infections, and the need for invasive interventions. Thirty-six device-related complications occurred in 31 patients in the S-ICD group of which bleedings were the most frequent. In the TV-ICD group, 49 complications occurred in 44 patients of which lead dysfunction was most frequent (HR: 0.69; P = 0.11). In both groups, half of all complications were within 30 days after implantation. Lead-related complications and systemic infections occurred significantly less in the S-ICD group compared with the TV-ICD group (P < 0.001, P = 0.03, respectively). Significantly more complications required invasive interventions in the TV-ICD group compared with the S-ICD group (8.3% vs. 4.3%, HR: 0.59; P = 0.047).

CONCLUSION

This secondary analysis shows that lead-related complications and systemic infections are more prevalent in the TV-ICD group compared with the S-ICD group. In addition, complications in the TV-ICD group were more severe as they required significantly more invasive interventions. This data contributes to shared decision-making in clinical practice.

Cardiac Implantable Electronic Devices Infection Assessment, Diagnosis and Management: A Review of the Literature

The use of increasingly complex cardiac implantable electronic devices (CIEDs) has increased exponentially in recent years. One of the most serious complications in terms of mortality, morbidity and financial burden is represented by infections involving these devices. They may affect only the generator pocket or be generalised with lead-related endocarditis. Modifiable and non-modifiable risk factors have been identified and they can be associated with patient or procedure characteristics or with the type of CIED. Pocket and systemic infections require a precise evaluation and a specialised treatment which in most cases involves the removal of all the components of the device and a personalised antimicrobial therapy. CIED retention is usually limited to cases where infection is unlikely or is limited to the skin incision site. Optimal re-implantation timing depends on the type of infection and on the results of microbiological tests. Preventive strategies, in the end, include antibiotic prophylaxis before CIED implantation, the possibility to use antibacterial envelopes and the prevention of hematomas. The aim of this review is to investigate the pathogenesis, stratification, diagnostic tools and management of CIED infections.

Predictors of pocket hematoma after cardiac implantable electronic device surgery: A nationwide cohort study

Purpose

Clinically significant pocket hematoma (CSH) is a common complication to cardiac implantable electronic device (CIED) surgery. We aimed to evaluate predictors of CSH after CIED surgery.

Methods

We performed a nationwide population-based prospective cohort study with systematic patient chart review of all Danish patients undergoing CIED surgery during a 12-month period. Multiple logistic regression analysis was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals for association between predictors and CSH.

Results

We included 5918 consecutive patients, 63% males, mean age 72.6 years. A total of 148 (2.5%) patients experienced CSH, including 10 patients (0.2%) requiring re-operation with hematoma evacuation. The risk of CSH was significantly increased in patients treated with aspirin (aOR 1.8; 1.2-2.7), aspirin and clopidogrel (aOR 3.9; 2.3-6.5), or heparin (aOR 2.1; 1.1-4.1), and in patients with INR≥2.0 (aOR 2.0; 1.2-3.2). Patients operated by low-volume operators (aOR 2.7; 1.6-4.6) or undergoing more complex CIED surgery such as cardiac resynchronization therapy (aOR 2.0; 1.1-3.5) or dual-chamber defibrillator (aOR 2.1; 1.2-3.8) also had significantly increased CSH risk.

Conclusion

In a large nationwide cohort of consecutive patients undergoing CIED surgery, the risk of CSH was 2.5%, with 0.2% necessitating evacuation. CSH risk was increased both in patients receiving aspirin, dual antiplatelet therapy or continued vitamin K-antagonist therapy. Dual antiplatelet therapy had the highest risk (aOR) of CSH. Both low operator volume and more complex CIED surgery were independently associated with higher CSH risk. These data should be considered when planning CIED surgery.

[Peri-interventional management of platelet aggregation inhibition and anticoagulation in urology]

Perioperative management of anticoagulation in patients receiving long-term anticoagulation or platelet aggregation inhibitors requires an individual consideration of competing risks. If the risk for bleeding is low, anticoagulation can often be continued. If it is necessary to pause anticoagulation, the necessity and dosage of bridging must be determined based on the individual risk of thromboembolism. Only patients with a high risk of thromboembolism should receive bridging in the full therapeutic dosage. The timing of pausing anticoagulation depends on the risk of bleeding from the urological intervention and the renal function of the patient. Platelet aggregation inhibitors should not be discontinued in the first month after coronary stent implantation, especially after acute coronary syndrome.

Risk Factors of Haematoma Formation Following Cardiac Implantable Electronic Device Procedures

PURPOSE

A single-centre cohort of 2,100 adults who consecutively underwent cardiac implantable electronic device procedures were retrospectively analysed to identify and quantify risk factors of perioperative pocket haematoma formation.

RESULTS

Dual antiplatelet therapy was significantly associated with increased odds of haematoma formation (OR 11.7 for aspirin and clopidogrel, OR 11.8 for aspirin and ticagrelor and OR 104 for aspirin and prasugrel, p<0.05) on multivariate binomial logistic regression analysis. Aspirin monotherapy was also associated with increased bleeding risk (OR 3.02, p<0.01). Direct oral anticoagulants and warfarin were also each associated with increased odds of haematoma formation although to a lesser extent than dual anti platelet therapy (DAPT). Amongst oral anticoagulants, apixaban was associated with the lowest bleeding risk (OR 2.59, p=0.03) whilst dabigatran was associated with the highest (OR 3.81, p=0.04). There was a significant incremental reduction in bleeding risk by 8% per 10x10³/μL increase in platelet count.

CONCLUSION

DAPT was associated with increased odds of pocket haematoma formation following cardiovascular implantable electronic device (CIED) procedure. This likelihood was higher than with oral anticoagulation therapy. Timely medication reconciliation of P2Y₁₂ inhibitors according to guidelines is important to avoid post-procedural bleeding complications. Perioperative policies which account for the half-life of withheld anticoagulant agents may help reduce the haematoma risk.

Complications in Device Therapy: Spectrum, Prevalence, and Management

PURPOSE OF REVIEW

Cardiac implantable electronic device implant numbers are continually increasing due to the expanding indications and ageing population. This review explores the complications associated with device therapy and discusses ways to minimise and manage such complications.

RECENT FINDINGS

Complications related to device therapy contribute to mortality and morbidity. Recent publications have detailed clear guidelines for appropriate cardiac device selection, as well as consensus documents discussing care quality and optimal implantation techniques. There have also been advances in device technologies that may offer alternative options to patients at high risk of/or already having encountered a complication. Adherence to guidelines, appropriate training, and selection of device, in addition to good surgical technique are key in reducing the burden of complications and improving acceptability of device therapy.