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Douketis JD, Spyropoulos AC. Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA 2024:2822177. [PMID: 39133476 DOI: 10.1001/jama.2024.12708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Importance Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism. Observations For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure. Conclusions and Relevance When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton, and McMaster University, Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York, New York
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Institute of Health System Science at the Feinstein Institutes for Medical Research, Manhasset, New York
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2
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Li M, Kim JB, Sastry BKS, Chen M. Infective endocarditis. Lancet 2024; 404:377-392. [PMID: 39067905 DOI: 10.1016/s0140-6736(24)01098-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/07/2024] [Accepted: 05/24/2024] [Indexed: 07/30/2024]
Abstract
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.
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Affiliation(s)
- Mingfang Li
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - B K S Sastry
- Department of Cardiology, Renova Century Hospital, Hyderabad, Telangana, India
| | - Minglong Chen
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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3
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Capiau A, De Vleeschauwer J, De Backer T, Gevaert S, Randon C, Mehuys E, Boussery K, Somers A. Optimizing anticoagulation therapy for in-hospital patients on direct oral anticoagulants: a single-centre modified Delphi study. Br J Clin Pharmacol 2024. [PMID: 38957976 DOI: 10.1111/bcp.16159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/23/2024] [Accepted: 06/09/2024] [Indexed: 07/04/2024] Open
Abstract
AIMS The management of patients treated with direct oral anticoagulants (DOACs) during hospitalization is a common challenge in clinical practice. Although bridging is generally not recommended, too often DOACs are switched to parenteral therapy with low molecular weight heparins. Our objectives were to update a local guideline for perioperative DOAC management and to develop a guideline for the anticoagulation management in non-surgical patients regarding temporary DOAC discontinuation. METHODS We executed a two-step modified Delphi study in a 1000-bed university hospital in Belgium. The Delphi questionnaires were developed based on a literature review and a telephone survey of prescribers. Two expert panels were established: one dedicated to perioperative DOAC management and the other to DOAC management in non-surgical patients. Both panels completed two rounds, commencing with an individual and online round, followed by a face-to-face group session. RESULTS After the two-round Delphi process, the updated perioperative guideline on DOAC management included reasons for delaying the resumption of DOACs following surgery, such as oral intake not possible, the probability of re-intervention within 3 days, and insufficient haemostasis (e.g. active clinically significant haematoma, haemorrhagic drains or wounds). Furthermore, a guideline for non-surgical hospitalized patients was developed, outlining possible reasons for interrupting DOAC therapy. Both guidelines offer clear anticoagulation therapy strategies corresponding to the identified scenarios. CONCLUSIONS We have updated and developed guidelines for DOAC management in surgical and non-surgical patients during hospitalization, which aim to support prescribers and to enhance targeted prescription review by hospital pharmacists.
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Affiliation(s)
- Andreas Capiau
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | | | - Tine De Backer
- Department of Cardiology, Heart Centre, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Sofie Gevaert
- Department of Cardiology, Heart Centre, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Caren Randon
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Annemie Somers
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
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4
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Kuschyk J, Sattler K, Fastenrath F, Rudic B, Akin I. [Treatment with cardiac electronic implantable devices]. Herz 2024; 49:233-246. [PMID: 38709278 DOI: 10.1007/s00059-024-05246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 05/07/2024]
Abstract
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.
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Affiliation(s)
- Jürgen Kuschyk
- I. Medizinische Klinik, Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Katherine Sattler
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Fabian Fastenrath
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Boris Rudic
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Ibrahim Akin
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
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5
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Lucà F, Oliva F, Giubilato S, Abrignani MG, Rao CM, Cornara S, Caretta G, Di Fusco SA, Ceravolo R, Parrini I, Murrone A, Geraci G, Riccio C, Gelsomino S, Colivicchi F, Grimaldi M, Gulizia MM. Exploring the Perioperative Use of DOACs, off the Beaten Track. J Clin Med 2024; 13:3076. [PMID: 38892787 PMCID: PMC11172442 DOI: 10.3390/jcm13113076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
A notable increase in direct oral anticoagulant (DOAC) use has been observed in the last decade. This trend has surpassed the prescription of vitamin K antagonists (VKAs) due to the absence of the need for regular laboratory monitoring and the more favorable characteristics in terms of efficacy and safety. However, it is very common that patients on DOACs need an interventional or surgical procedure, requiring a careful evaluation and a challenging approach. Therefore, perioperative anticoagulation management of patients on DOACs represents a growing concern for clinicians. Indeed, while several surgical interventions require temporary discontinuation of DOACs, other procedures that involve a lower risk of bleeding can be conducted, maintaining a minimal or uninterrupted DOAC strategy. Therefore, a comprehensive evaluation of patient characteristics, including age, susceptibility to stroke, previous bleeding complications, concurrent medications, renal and hepatic function, and other factors, in addition to surgical considerations, is mandatory to establish the optimal discontinuation and resumption timing of DOACs. A multidisciplinary approach is required for managing perioperative anticoagulation in order to establish how to face these circumstances. This narrative review aims to provide physicians with a practical guide for DOAC perioperative management, addressing the most controversial issues.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89124 Reggio Calabria, Italy;
| | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy;
| | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy;
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89124 Reggio Calabria, Italy;
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy
| | | | - Roberto Ceravolo
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy;
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy;
| | - Adriano Murrone
- Cardiology Unit, Città di Castello Hospital, 06012 Città di Castello, Italy;
| | - Giovanna Geraci
- Cardiology Department, Sant’Antonio Abate Hospital, ASP Trapani, 91100 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 95122 Caserta, Italy;
| | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands;
| | - Furio Colivicchi
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy; (S.A.D.F.); (F.C.)
| | - Massimo Grimaldi
- Cardiology Department, F. Miulli Hospital, Acquaviva delle Fonti, 70021 Bari, Italy;
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Matteucci A, Pignalberi C, Pandozi C, Magris B, Meo A, Russo M, Galeazzi M, Schiaffini G, Aquilani S, Di Fusco SA, Colivicchi F. Prevention and Risk Assessment of Cardiac Device Infections in Clinical Practice. J Clin Med 2024; 13:2707. [PMID: 38731236 PMCID: PMC11084741 DOI: 10.3390/jcm13092707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 04/28/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
The implantation of cardiac electronic devices (CIEDs), including pacemakers and defibrillators, has become increasingly prevalent in recent years and has been accompanied by a significant rise in cardiac device infections (CDIs), which pose a substantial clinical and economic burden. CDIs are associated with hospitalizations and prolonged antibiotic therapy and often necessitate device removal, leading to increased morbidity, mortality, and healthcare costs worldwide. Approximately 1-2% of CIED implants are associated with infections, making this a critical issue to address. In this contemporary review, we discuss the burden of CDIs with their risk factors, healthcare costs, prevention strategies, and clinical management.
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Affiliation(s)
- Andrea Matteucci
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
- Department of Experimental Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Carlo Pignalberi
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Claudio Pandozi
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Barbara Magris
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Antonella Meo
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Maurizio Russo
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Marco Galeazzi
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Giammarco Schiaffini
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Stefano Aquilani
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
| | | | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
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7
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Alfano G, Morisi N, Giovanella S, Frisina M, Amurri A, Tei L, Ferri M, Ligabue G, Donati G. Risk of infections related to endovascular catheters and cardiac implantable devices in hemodialysis patients. J Vasc Access 2024:11297298241240502. [PMID: 38506890 DOI: 10.1177/11297298241240502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
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.
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Affiliation(s)
- Gaetano Alfano
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
| | - Niccolò Morisi
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Silvia Giovanella
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Monica Frisina
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Alessio Amurri
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Lorenzo Tei
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
- Nephrology and Dialysis Unit, Azienda USL di Modena, Modena, Emilia-Romagna, Italy
| | - Maria Ferri
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Giulia Ligabue
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Gabriele Donati
- Nephrology, Dialysis and Kidney Transplant Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Emilia-Romagna, Italy
- Surgical, Medical, Dental and Morphological Sciences Department (CHIMOMO), University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
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8
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Krieger K, Park I, Althoff T, Busch S, Chun KRJ, Estner H, Iden L, Maurer T, Rillig A, Sommer P, Steven D, Tilz R, Duncker D. [Perioperative management for cardiovascular implantable electronic devices]. Herzschrittmacherther Elektrophysiol 2024; 35:83-90. [PMID: 38289503 PMCID: PMC10879261 DOI: 10.1007/s00399-023-00989-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/02/2024] [Indexed: 02/21/2024]
Abstract
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.
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Affiliation(s)
- Konstantin Krieger
- Klinik für Kardiologie, Asklepios Klinikum Harburg, Eißendorfer Pferdeweg 52, 21075, Hamburg, Deutschland.
| | - Innu Park
- Klinik für Kardiologie, Asklepios Klinikum Harburg, Eißendorfer Pferdeweg 52, 21075, Hamburg, Deutschland
| | - Till Althoff
- Klinik für Kardiologie u. Angiologie, Charite - Universitätsmedizin Medizin Berlin, Berlin, Deutschland, Charitéplatz 1, 10117
- Arrhythmia Section, Cardiovascular Institute (ICCV), CLÍNIC - University Hospital Barcelona, Barcelona, Spanien, C. de Villarroel, 170, 08036
| | - Sonia Busch
- Abteilung für Elektrophysiologie, Herz-Zentrum Bodensee, Konstanz, Deutschland, Luisenstraße 9A, 78464
| | - K R Julian Chun
- Cardioangiologisches Centrum Bethanien - CCB, Frankfurt am Main, Deutschland, Im Prüfling 23, 60389
| | - Heidi Estner
- Medizinische Klinik und Poliklinik I, LMU Klinikum der Universität München, München, Deutschland, Ziemssenstraße 5, 80336
| | - Leon Iden
- Klinik für Kardiologie, Herz- und Gefäßzentrum Bad Segeberg, Bad Segeberg, Deutschland, Am Kurpark 1, 23795
| | - Tilman Maurer
- Klinik für Kardiologie, Asklepios Klinik St. Georg, Hamburg, Deutschland, Lohmühlenstraße 5, 20099
| | - Andreas Rillig
- Universitäres Herz- und Gefäßzentrum Hamburg, Universitätsklinikum Eppendorf Hamburg, Hamburg, Deutschland, Martinistraße 52, 20251
| | - Philipp Sommer
- Med. Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland, Georgstraße 11, 32545
| | - Daniel Steven
- Abteilung für Elektrophysiologie, Herzzentrum der Uniklinik Köln, Köln, Deutschland, Kerpener Straße 62, 50937
| | - Roland Tilz
- Klinik für Elektrophysiologie, Medizinische Klinik II, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein (UKSH), Lübeck, Deutschland, Ratzeburger Allee 160, 23562
| | - David Duncker
- Hannover Herzrhythmus Centrum, Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Deutschland, Carl-Neuberg-Straße 1, 30625
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9
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Baddour LM, Esquer Garrigos Z, Rizwan Sohail M, Havers-Borgersen E, Krahn AD, Chu VH, Radke CS, Avari-Silva J, El-Chami MF, Miro JM, DeSimone DC. 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. Circulation 2024; 149:e201-e216. [PMID: 38047353 DOI: 10.1161/cir.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
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.
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10
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Di Biase L, Lakkireddy DJ, Marazzato J, Velasco A, Diaz JC, Navara R, Chrispin J, Rajagopalan B, Natale A, Mohanty S, Zhang X, Della Rocca D, Dalal A, Park K, Wiley J, Batchelor W, Cheung JW, Dangas G, Mehran R, Romero J. Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:82-108. [PMID: 38171713 DOI: 10.1016/j.jacc.2023.09.831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/24/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024]
Abstract
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.
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Affiliation(s)
- Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA.
| | | | - Jacopo Marazzato
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alejandro Velasco
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Juan Carlos Diaz
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rachita Navara
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | | | - Xiaodong Zhang
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Aarti Dalal
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ki Park
- Department of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Jose Wiley
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Wayne Batchelor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - George Dangas
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jorge Romero
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
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11
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 231] [Impact Index Per Article: 231.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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12
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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13
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Kalfon E, Ayala-Paredes F. To Stop or Not to Stop DOACs During CIED Surgery, Is That the Question? JACC Clin Electrophysiol 2024; 10:133-134. [PMID: 38069970 DOI: 10.1016/j.jacep.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Eli Kalfon
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel; Cardiology Department, University Hospital of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Felix Ayala-Paredes
- Cardiology Department, University Hospital of Sherbrooke, Sherbrooke, Quebec, Canada.
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14
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Creta A, Ventrella N, Earley MJ, Finlay M, Sporton S, Maclean E, Kanthasamy V, Lemos Silva Di Nubila BC, Ricciardi D, Calabrese V, Picarelli F, Hunter RJ, Lambiase PD, Schilling RJ, Grigioni F, Monkhouse C, Muthumala A, Moore P, Providencia R, Chow A. DOACs vs Vitamin K Antagonists During Cardiac Rhythm Device Surgery: A Multicenter Propensity-Matched Study. JACC Clin Electrophysiol 2024; 10:121-132. [PMID: 37897463 DOI: 10.1016/j.jacep.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 08/24/2023] [Accepted: 08/30/2023] [Indexed: 10/30/2023]
Abstract
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.
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Affiliation(s)
- Antonio Creta
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Health Informatics, University College London, London, United Kingdom.
| | | | - Mark J Earley
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Malcolm Finlay
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Sporton
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Edward Maclean
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | | | - Danilo Ricciardi
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Vito Calabrese
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | | | - Ross J Hunter
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Pier D Lambiase
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | | | | | - Amal Muthumala
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Philip Moore
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Rui Providencia
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Institute of Health Informatics, University College London, London, United Kingdom
| | - Anthony Chow
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
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15
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Zheng XY, Feng GW, Guo J, Xie F, Li X, Zhang MZ, Zhang XF, Wu XF, Ding YJ. A cross-sectional study of appropriateness evaluation of anticoagulation therapy for inpatients with nonvalvular atrial fibrillation. Front Pharmacol 2023; 14:1286559. [PMID: 38116077 PMCID: PMC10728771 DOI: 10.3389/fphar.2023.1286559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
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.
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Affiliation(s)
- Xiao-Yuan Zheng
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Guang-Wei Feng
- Department of Pharmacy, Dahua Hospital, Xuhui District, Shanghai, China
| | - Jing Guo
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Fen Xie
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Xia Li
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Ming-Zhu Zhang
- Department of Pharmacy, Shandong Provincial Third Hospital, Jinan, China
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical University, Xuzhou, China
| | - Xiu-Fen Zhang
- Oncology Institute, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Xiu-Feng Wu
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Yong-Juan Ding
- Department of Pharmacy, Affiliated Hospital of Jiangnan University, Wuxi, China
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16
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Howard TS, Vinocur JM. Translation of Tools and Techniques from the Adult Electrophysiology World to Pediatric Cardiac Implantable Electronic Devices. Card Electrophysiol Clin 2023; 15:515-525. [PMID: 37865524 DOI: 10.1016/j.ccep.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
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.
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Affiliation(s)
- Taylor S Howard
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, 6651 Main Street, E1920, Houston, TX 77030, USA.
| | - Jeffrey M Vinocur
- Department of Pediatrics, Division of Pediatric Cardiology, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
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17
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 186] [Impact Index Per Article: 186.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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18
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Lucà F, Oliva F, Abrignani MG, Di Fusco SA, Parrini I, Canale ML, Giubilato S, Cornara S, Nesti M, Rao CM, Pozzi A, Binaghi G, Maloberti A, Ceravolo R, Bisceglia I, Rossini R, Temporelli PL, Amico AF, Calvanese R, Gelsomino S, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios. J Clin Med 2023; 12:5955. [PMID: 37762897 PMCID: PMC10531873 DOI: 10.3390/jcm12185955] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | | | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | - Iris Parrini
- Cardiology Department, Ospedale Mauriziano, 10128 Turin, Italy
| | - Maria Laura Canale
- Cardiology Department, Nuovo Ospedale Versilia Lido di Camaiore Lucca, 55049 Camaiore, Italy
| | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy
| | - Giulio Binaghi
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09047 Cagliari, Italy
| | - Alessandro Maloberti
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 88046 Lamezia, Italy
| | - Irma Bisceglia
- Integrated Cardiology Services, Department of Cardio-Thoracic-Vascular, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy
| | - Roberta Rossini
- Cardiology Unit, Ospedale Santa Croce e Carle, 12100 Cuneo, Italy;
| | - Pier Luigi Temporelli
- Division of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, 28010 Gattico-Veruno, Italy
| | | | | | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
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19
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Regoli FD, Saguner AM, Auricchio A, Demarchi A, Pasotti E, Conte G, Caputo ML, Özkartal T, Breitenstein A. Peri-Procedural Management of Direct-Acting Oral Anticoagulants (DOACs) in Transcatheter Miniaturized Leadless Pacemaker Implantation. J Clin Med 2023; 12:4814. [PMID: 37510929 PMCID: PMC10381618 DOI: 10.3390/jcm12144814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/07/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
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.
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Affiliation(s)
- François Diederik Regoli
- Service of Cardiology, Hospital of San Giovanni, Cardiocentro Ticino Institute, 6500 Bellinzona, Switzerland
- Cardiology Department, Cardiocentro Ticino Institute, 6900 Lugano, Switzerland
| | - Ardan M Saguner
- University Heart Center Zurich, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Angelo Auricchio
- Cardiology Department, Cardiocentro Ticino Institute, 6900 Lugano, Switzerland
| | - Andrea Demarchi
- Cardiology Department, Cardiocentro Ticino Institute, 6900 Lugano, Switzerland
| | - Elena Pasotti
- Cardiology Department, Cardiocentro Ticino Institute, 6900 Lugano, Switzerland
| | - Giulio Conte
- Cardiology Department, Cardiocentro Ticino Institute, 6900 Lugano, Switzerland
| | - Maria Luce Caputo
- Cardiology Department, Cardiocentro Ticino Institute, 6900 Lugano, Switzerland
| | - Tardu Özkartal
- Cardiology Department, Cardiocentro Ticino Institute, 6900 Lugano, Switzerland
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20
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Soler-Espejo E, Esteve-Pastor MA, Rivera-Caravaca JM, Roldan V, Marín F. Reducing bleeding risk in patients on oral anticoagulation therapy. Expert Rev Cardiovasc Ther 2023; 21:923-936. [PMID: 37905915 DOI: 10.1080/14779072.2023.2275662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/23/2023] [Indexed: 11/02/2023]
Abstract
INTRODUCTION Oral anticoagulation (OAC) significantly mitigates thromboembolism risks in atrial fibrillation (AF) and venous thromboembolism (VTE) patients yet concern about major bleeding events persist. In fact, clinically relevant hemorrhages can be life-threatening. Bleeding risk is dynamic and influenced by factors such as age, new comorbidities, and drug therapies, and should not be assessed solely based on static baseline factors. AREAS COVERED We comprehensively review the bleeding risk associated with OAC therapy. Emphasizing the importance of assessing both thromboembolic and bleeding risks, we present clinical tools for estimating stroke and systemic embolism (SSE) and bleeding risk in AF and VTE patients. We also address overlapping risk factors and the dynamic nature of bleeding risk. EXPERT OPINION The OAC management is undergoing constant transformation, motivated by the primary objective of mitigating thromboembolism and bleeding hazards, thereby amplifying patient safety throughout the course of treatment. The future of OAC embraces personalized approaches and innovative therapies, driven by advanced pathophysiological insights and technological progress. This holds promise for improving patient outcomes and revolutionizing anticoagulation practices.
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Affiliation(s)
- Eva Soler-Espejo
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Faculty of Nursing, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
| | - Vanessa Roldan
- Department of Hematology and Hemotherapy, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), CIBERCV, Murcia, Spain
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21
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Douketis JD, Spyropoulos AC. Perioperative Management of Anticoagulant and Antiplatelet Therapy. NEJM EVIDENCE 2023; 2:EVIDra2200322. [PMID: 38320132 DOI: 10.1056/evidra2200322] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
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.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada
| | - Alex C Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Service, Northwell Health at Lenox Hill Hospital, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, New York
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22
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Rao MY, Sullivan PM, Takao C, Badran S, Patel ND. Safety of Continuing Anticoagulation Prior to Cardiac Catheterization in Pediatric Patients: A Los Angeles Center Experience. Pediatr Cardiol 2023; 44:1009-1013. [PMID: 36725724 PMCID: PMC10224819 DOI: 10.1007/s00246-023-03097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Mounica Y Rao
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Patrick M Sullivan
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Cheryl Takao
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sarah Badran
- Congenital Heart Center, Spectrum Health Helen DeVos Children's Hospital, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Neil D Patel
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Division of Cardiology, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS 34, Los Angeles, CA, USA.
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Martin AC, Weizman O, Sellal JM, Algalarrondo V, Amara W, Bouzeman A, Gandjbakhch E, Lellouche N, Louembe J, Menet A, Roumegou P, Treguer F, Godier A, Boveda S, Garcia R, Marijon E. Impact of peri-procedural management of direct oral anticoagulants on pocket haematoma after cardiac electronic device implantation: the StimAOD multicentre prospective study. Europace 2023; 25:euad057. [PMID: 36932714 PMCID: PMC10227661 DOI: 10.1093/europace/euad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/17/2023] [Indexed: 03/19/2023] Open
Abstract
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.
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Affiliation(s)
- Anne-Céline Martin
- Department of Cardiology, AP HP, European Hospital Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, 4 Rue de l'Observatoire 75006 Paris, France
| | - Orianne Weizman
- Department of Cardiology, AP HP, European Hospital Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75015 Paris, France
| | - Jean-Marc Sellal
- Department of Cardiology, Nancy University Hospital, Rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
- IADI, INSERM U1254, Université de Lorraine, Rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - Vincent Algalarrondo
- Department of Cardiology, Rhythm Disorders Unit, Bichat Hospital, AP-HP, 46 Rue Henri Huchard, 75018 Paris, France
- Paris Cité University, Paris, France
| | - Walid Amara
- Department of Cardiology, GHI Le Raincy Montfermeil, 10 Rue du Général Leclerc, 93370 Montfermeil, France
| | - Abdeslam Bouzeman
- Department of Cardiology, Parly 2 Private Hospital, 21 Rue Moxouris, 78150 Le Chesnay-Rocquencourt, France
| | - Estelle Gandjbakhch
- Department of Cardiology, Pitié-Salpêtrière University Hospital, Institute of Cardiology, 47-83 Bd de l'Hôpital, 75013 Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, 1166 Paris, France
| | - Nicolas Lellouche
- Department of Cardiology, Hôpital Henri MONDOR, AP-HP, 1 Rue Gustave Eiffel, 94000 Créteil, France
| | - Jules Louembe
- Department of Cardiology, Hôpital d’Instruction des Armées Percy, 2 Rue Lieutenant Raoul Batany, 92140 Clamart, France
| | - Aymeric Menet
- Laboratoire ETHICS, Groupement des Hôpitaux de l'Institut Catholique de Lille, Service de Cardiologie USIC, Université Catholique de Lille, Rue du Grand But, 59400 Lille, France
| | - Pierre Roumegou
- Department of Cardiology, University Hospital Poitiers, 2 Rue de la Milétrie, 86000 Poitiers, France
| | - Frederic Treguer
- Department of Cardiology, Clinique Saint Joseph, 51 Rue de la Foucaudière, 49800 Trélazé, France
| | - Anne Godier
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, 4 Rue de l'Observatoire 75006 Paris, France
- Department of Anaesthesiology and Critical Care, APHP, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
| | - Serge Boveda
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75015 Paris, France
- Cardiology—Heart Rhythm Management Department, Clinique Pasteur, 45 Avenue de Lombez, 31076 Toulouse, France
- Universiteit Ziekenhuis, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Jette Brussels, Belgium
| | - Rodrigue Garcia
- Department of Cardiology, University Hospital Poitiers, 2 Rue de la Milétrie, 86000 Poitiers, France
- CIC1402, University Hospital of Poitiers, 86021 Poitiers, France
| | - Eloi Marijon
- Department of Cardiology, AP HP, European Hospital Georges Pompidou, 20 rue Leblanc, 75015 Paris, France
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75015 Paris, France
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Golian M, Sadek MM, Aydin A, Davis D, Green M, Klein A, Nair GM, Nery P, Ramirez FD, Redpath C, Hansom SP, Wells GA, Birnie DH. A Randomized Trial of Lenient Versus Strict Arm Instruction Post Cardiac Device Surgery (LENIENT). Am Heart J 2023; 259:52-57. [PMID: 36708911 DOI: 10.1016/j.ahj.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 05/11/2023]
Abstract
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.
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Affiliation(s)
- Mehrdad Golian
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Mouhannad M Sadek
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Alper Aydin
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Darryl Davis
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Martin Green
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Andres Klein
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Girish M Nair
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Pablo Nery
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - F Daniel Ramirez
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Calum Redpath
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Simon P Hansom
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George A Wells
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H Birnie
- Division of Cardiology / Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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25
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Iatrogenic Strokes and Covert Brain Infarcts After Percutaneous Cardiac Procedures: An Update. Can J Cardiol 2023; 39:200-209. [PMID: 36435326 DOI: 10.1016/j.cjca.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
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.
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26
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Rodríguez-Fernández M, López Cortés LE. Patogenia, factores de riesgo y prevención de las infecciones de dispositivos de estimulación cardiaca. CIRUGIA CARDIOVASCULAR 2023. [DOI: 10.1016/j.circv.2022.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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27
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Pocket histology at cardiac implantable electronic device replacement: What's new? Heart Rhythm 2023; 20:198-206. [PMID: 36309157 DOI: 10.1016/j.hrthm.2022.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/04/2022]
Abstract
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.
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Kadado AJ, Chalhoub F. Periprocedural anticoagulation therapy in patients undergoing micra leadless pacemaker implantation. Int J Cardiol 2023; 371:221-225. [PMID: 36115436 DOI: 10.1016/j.ijcard.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/24/2022] [Accepted: 09/12/2022] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Anis John Kadado
- UMass Chan Medical School - Baystate, Department of Cardiology, Springfield, MA, USA.
| | - Fadi Chalhoub
- UMass Chan Medical School - Baystate, Department of Cardiology, Springfield, MA, USA
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29
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Alvarez CK, Zweibel S, Stangle A, Panza G, May T, Marieb M. Anesthetic Considerations in the Electrophysiology Laboratory: A Comprehensive Review. J Cardiothorac Vasc Anesth 2023; 37:96-111. [PMID: 36357307 DOI: 10.1053/j.jvca.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 10/02/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Chikezie K Alvarez
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT; University of Connecticut, Farmington, CT.
| | - Steven Zweibel
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT
| | - Alexander Stangle
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT; University of Connecticut, Farmington, CT
| | - Gregory Panza
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT; University of Connecticut, Farmington, CT
| | - Thomas May
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT
| | - Mark Marieb
- Hartford HealthCare Heart and Vascular Institute, Hartford, CT; Griffin Hospital, Derby, CT
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30
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Metze M, Siegemund A, Siegemund T, Klöter T, Stöbe S, Laufs U, Petros S, Pfrepper C. The dose–response of direct oral anticoagulants is non‐linear at plasma levels below 100 ng/ml. Int J Lab Hematol 2022; 45:e60-e63. [PMID: 36539973 DOI: 10.1111/ijlh.14004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Michael Metze
- Department of Cardiology, Medical Department IV University Hospital Leipzig Leipzig Germany
| | | | | | - Tristan Klöter
- Department of Cardiology, Medical Department IV University Hospital Leipzig Leipzig Germany
| | - Stephan Stöbe
- Department of Cardiology, Medical Department IV University Hospital Leipzig Leipzig Germany
| | - Ulrich Laufs
- Department of Cardiology, Medical Department IV University Hospital Leipzig Leipzig Germany
| | - Sirak Petros
- Medical ICU University Hospital Leipzig Leipzig Germany
- Division of Hemostaseology, Medical Department I University Hospital Leipzig Leipzig Germany
| | - Christian Pfrepper
- Division of Hemostaseology, Medical Department I University Hospital Leipzig Leipzig Germany
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31
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Llewellyn J, Ezeonwumelu C, Jackson L, Rao A. Anticoagulation for Patients Undergoing Implantation of a Cardiac Implantable Electronic Device. Br J Hosp Med (Lond) 2022; 83:1-6. [PMID: 36594775 DOI: 10.12968/hmed.2022.0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Jennifer Llewellyn
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | | | - Lynsey Jackson
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Archana Rao
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
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32
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Shah S, Nayfeh T, Hasan B, Urtecho M, Firwana M, Saadi S, Abd-Rabu R, Nanaa A, Flynn DN, Rajjoub NS, Hazem W, Seisa MO, Hassett LC, Spyropoulos AC, Douketis JD, Murad MH. Perioperative Management of Vitamin K Antagonists and Direct Oral Anticoagulants: A Systematic Review and Meta-analysis. Chest 2022; 163:1245-1257. [PMID: 36462533 DOI: 10.1016/j.chest.2022.11.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/30/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The management of patients who are receiving chronic oral anticoagulation therapy and require an elective surgery or an invasive procedure is a common clinical scenario. RESAERCH QUESTION What is the best available evidence to support the development of American College of Chest Physicians guidelines on the perioperative management of patients who are receiving long-term vitamin K agonist (VKA) or direct oral anticoagulant (DOAC) and require elective surgery or procedures? STUDY DESIGH AND METHODS A literature search including multiple databases from database inception through July 16, 2020, was performed. Meta-analyses were conducted when appropriate. RESULTS In patients receiving VKA (warfarin) undergoing elective noncardiac surgery, shorter (< 5 days) VKA interruption is associated with an increased risk of major bleeding. In patients who required VKA interruption, heparin bridging (mostly with low-molecular-weight heparin [LMWH]) was associated with a statistically significant increased risk of major bleed (relative risk [RR], 9.1; 95% CI, 1.62-51.3), representing a very low certainty of evidence (COE). Compared with DOAC interruption 1 to 4 days before surgery, continuing DOACs was not associated with a statistically significant difference in the risk of bleeding, representing a very low COE. Continuing dabigatran was associated with a statistically significant increased risk of thromboembolism (RR, 2.2; 95% CI, 1.3-3.8), representing a low COE. In patients who needed DOAC interruption, bridging with LMWH was associated a with statistically significant increased risk of minor bleeding compared with no bridging (RR, 1.7; 95% CI, 1.13-2.7), representing a low COE. INTERPRETATION The certainty in the evidence supporting the perioperative management of anticoagulants remains limited. No high-quality evidence exists to support the practice of heparin bridging during the interruption of VKA or DOAC therapy for an elective surgery or procedure or for the practice of interrupting VKA therapy for minor procedures, including cardiac device implantation, or continuation of a DOAC vs short-term interruption of a DOAC (1-4 days) in the perioperative period.
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Affiliation(s)
- Sahrish Shah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Tarek Nayfeh
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Meritxell Urtecho
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mohammed Firwana
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Samer Saadi
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rami Abd-Rabu
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Ahmad Nanaa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - David N Flynn
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Noora S Rajjoub
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Walid Hazem
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mohamed O Seisa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Alex C Spyropoulos
- Institute of Health Systems Science-Feinstein Institutes for Medical Research and The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 90] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Olsen T, Jørgensen OD, Nielsen JC, Thøgersen AM, Philbert BT, Frausing MHJP, Sandgaard NCF, Johansen JB. Risk factors for cardiac implantable electronic device infections: a nationwide Danish study. Eur Heart J 2022; 43:4946-4956. [PMID: 36263789 PMCID: PMC9748591 DOI: 10.1093/eurheartj/ehac576] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/05/2022] [Accepted: 09/29/2022] [Indexed: 01/12/2023] Open
Abstract
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.
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Affiliation(s)
- Thomas Olsen
- Corresponding author. Tel: +45 2635 1337, Fax: +45 6541 3003,
| | - Ole Dan Jørgensen
- Department of Heart, Lung and Vascular Surgery, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Region of Southern Denmark, Denmark,Danish Pacemaker and ICD Register, Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Region of Southern Denmark, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Central Denmark Region, Denmark,Danish Pacemaker and ICD Register, Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Region of Southern Denmark, Denmark
| | - Anna Margrethe Thøgersen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, North Denmark Region, Denmark
| | - Berit Thornvig Philbert
- Department of Cardiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Capital Region of Denmark, Denmark,Danish Pacemaker and ICD Register, Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Region of Southern Denmark, Denmark
| | - Maria Hee Jung Park Frausing
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Central Denmark Region, Denmark
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Cardiac Implantable Electronic Devices Infection Assessment, Diagnosis and Management: A Review of the Literature. J Clin Med 2022; 11:jcm11195898. [PMID: 36233765 PMCID: PMC9570622 DOI: 10.3390/jcm11195898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 12/05/2022] Open
Abstract
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.
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Salerno DM, Lee-Riddle GS, Brar S, Samstein B, Brown RS, Lennon C. Deceased donor liver transplantation in patients on direct oral anticoagulants at the time of transplant surgery: A case series. Liver Transpl 2022; 28:1681-1684. [PMID: 35657735 DOI: 10.1002/lt.26521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/27/2022] [Accepted: 05/17/2022] [Indexed: 01/13/2023]
Affiliation(s)
- David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Grace S Lee-Riddle
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Seema Brar
- Department of Anesthesiology, Weill Cornell Medical Center, New York, New York, USA
| | - Benjamin Samstein
- Department of Surgery, Weill Cornell Medical Center, New York, New York, USA
| | - Robert S Brown
- Department of Medicine, Weill Cornell Medical Center, New York, New York, USA
| | - Christine Lennon
- Department of Anesthesiology, Weill Cornell Medical Center, New York, New York, USA
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Prevention and Management of Cardiac Implantable Electronic Device Infections: State-of-the-Art and Future Directions. Heart Lung Circ 2022; 31:1482-1492. [PMID: 35989213 DOI: 10.1016/j.hlc.2022.06.690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 06/09/2022] [Accepted: 06/19/2022] [Indexed: 11/23/2022]
Abstract
Cardiac implantable electronic device (CIED) infection is an increasingly common complication of device therapy. CIED infection confers significant patient morbidity and health care expenditure, hence it is essential that clinicians recognise the contemporary strategies for predicting, reducing and treating these events. Recent technological advances-in particular, the development of antimicrobial envelopes, leadless devices and validated risk scores-present decision-makers with novel strategies for managing this expanding patient population. This review summarises the key issues facing CIED patients and their physicians, and explores the supporting evidence for the latest therapeutic developments in this field.
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Llewellyn J, Garner D, Rao A. Complications in Device Therapy: Spectrum, Prevalence, and Management. Curr Heart Fail Rep 2022; 19:316-324. [PMID: 35932445 DOI: 10.1007/s11897-022-00563-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
- J Llewellyn
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK.
| | - D Garner
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Road, Upton, Wirral, CH49 5PE, UK
| | - A Rao
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
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Phillips P, Krahn AD, Andrade JG, Chakrabarti S, Thompson CR, Harris DJ, Forman JM, Karim SS, Sterns LD, Fedoruk LM, Partlow E, Bashir J. Treatment and Prevention of Cardiovascular Implantable Electronic Device (CIED) Infections. CJC Open 2022; 4:946-958. [DOI: 10.1016/j.cjco.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/03/2022] [Indexed: 10/15/2022] Open
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Waddingham PH, Elliott J, Bates A, Bilham J, Muthumala A, Honarbakhsh S, Ullah W, Hunter RJ, Lambiase PD, Lane RE, Chow AWC. Iatrogenic cardiac perforation due to pacemaker and defibrillator leads: a contemporary multicentre experience. Europace 2022; 24:1824-1833. [PMID: 35894862 DOI: 10.1093/europace/euac105] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS To determine the incidence, clinical features, management, and outcomes of pacemaker (PM) and implantable cardioverter-defibrillator (ICD) lead cardiac perforation. Cardiac perforations due to PM and ICD leads are rare but serious complications. Clinical features vary widely and may cause diagnostic delay. Management strategies are non-guideline based due to paucity of data. METHODS AND RESULTS A multicentre retrospective series including 3 UK cardiac tertiary centres from 2016 to 2020. Patient, device, and lead characteristics were obtained including 6-month outcomes. Seventy cases of perforation were identified from 10 631 procedures; perforation rate was 0.50% for local implants. Thirty-nine (56%) patients were female, mean ( ± standard deviation) age 74 ( ± 13.8) years. Left ventricular ejection fraction 51 ( ± 13.2) %. Median time to diagnosis was 9 (range: 0-989) days. Computed tomography (CT) diagnosed perforation with 97% sensitivity. Lead parameter abnormalities were present in 86% (whole cohort) and 98.6% for perforations diagnosed >24 h. Chest pain was the commonest symptom, present in 46%. The management strategy was percutaneous in 98.6% with complete procedural success in 98.6%. Pericardial effusion with tamponade was present in 17% and was associated with significantly increased mortality and major complications. Anticoagulation status was associated with tamponade by multivariate analysis (odds ratio 21.7, 95% confidence interval: 1.7-275.5, P = 0.018). CONCLUSIONS Perforation was rare (0.50%) and managed successfully by a percutaneous strategy with good outcomes. Tamponade was associated with increased mortality and major complications. Anticoagulation status was an independent predictor of tamponade. Case complexity is highly variable and requires skilled operators with a multi-disciplinary approach to achieve good outcomes.
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Affiliation(s)
- Peter H Waddingham
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | - James Elliott
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Alexander Bates
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - James Bilham
- Harefield Hospital, Royal Brompton, and Harefield NHS Trust, London, UK
| | - Amal Muthumala
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Shohreh Honarbakhsh
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | - Waqas Ullah
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ross J Hunter
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
| | - Pier D Lambiase
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Rebecca E Lane
- Harefield Hospital, Royal Brompton, and Harefield NHS Trust, London, UK
| | - Anthony W C Chow
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
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Recurrence of LV Thrombus in a Patient with Severe Ischaemic Cardiomyopathy Anticoagulated with Apixaban. Case Rep Cardiol 2022; 2022:8156942. [PMID: 35911864 PMCID: PMC9334074 DOI: 10.1155/2022/8156942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 07/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background Anticoagulation with warfarin remains the mainstay treatment for left ventricular thrombi. Although successful thrombus resolution has been reported with direct oral anticoagulants' (DOACs') recurrence/progression while resuming Apixaban therapy is yet to be reported. Case Presentation. This case report describes left ventricular thrombus progression/recurrence in a patient anticoagulated with Apixaban undergoing implantable cardioverter defibrillator to cardiac resynchronisation therapy with defibrillator upgrade procedure. He was thereafter changed to warfarin. Contrast echocardiogram at 6 months follow-up did not identify the previously demonstrated mural thrombus. Conclusion Prospective randomised control trials should be conducted in patients with left ventricular thrombus to compare anticoagulants, assess the efficacy and safety of DOACs, and evaluate uninterrupted DOAC versus transient withdrawal for cardiac device procedures.
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper. Thromb Haemost 2022; 122:1625-1652. [PMID: 35793691 DOI: 10.1055/s-0042-1750385] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
While there is a clear clinical benefit of oral anticoagulation in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision for initiating and continuing anticoagulation is often based on a careful assessment of both thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static "one-off" assessment based on baseline factors but is dynamic, being influenced by aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a view to summarizing "best practice" when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, and review established bleeding risk factors and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism, are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom.,Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge and Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, München, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Vogler J, Castro L, Tilz RR. Neue ESC-Leitlinien zur Herzschrittmacher- und Resynchronisationstherapie – Patientenevaluation und Implantation. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1732-5687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDie Herzschrittmachertherapie ist ein wesentlicher Teil der klinischen Elektrophysiologie sowie der allgemeinen Kardiologie. Auch wenn sich im Bereich manch klarer Indikationen über die
Jahre wenig verändert hat, sind seit der Publikation der ESC-Leitlinien zur Schrittmachertherapie im Jahr 2013 neue Erkenntnisse z. B. im Bereich der Schrittmachertherapie bei Synkope, nach
TAVI, der kardialen Resynchronisationstherapie und dem Conduction-System-Pacing hinzugekommen. Eine wesentliche Bedeutung kommt daneben sowohl der präoperativen Evaluation eines Patienten
mit vermuteter oder dokumentierter Bradykardie als auch der eigentlichen Implantation und dem perioperativen Management zu. Im Fokus stehen dabei eine standardisierte Diagnostik zur
Abklärung der Indikation sowie die Vermeidung von Komplikationen während der Implantation.
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Affiliation(s)
- Julia Vogler
- Klinik für Rhythmologie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Deutschland
| | - Liesa Castro
- Klinik für Rhythmologie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Deutschland
| | - Roland Richard Tilz
- Klinik für Rhythmologie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Deutschland
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Tarakji KG, Korantzopoulos P, Philippon F, Biffi M, Mittal S, Poole JE, Kennergren C, Lexcen DR, Lande JD, Hilleren G, Seshadri S, Wilkoff BL. Risk factors for hematoma in patients undergoing cardiac device procedures: A WRAP-IT trial analysis. Heart Rhythm O2 2022; 3:466-473. [PMID: 36340491 PMCID: PMC9626743 DOI: 10.1016/j.hroo.2022.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background Implant site hematoma is a known complication of cardiac device procedures and can lead to major consequences. Objectives To evaluate risk factors for hematoma and further understand the relationship between anticoagulant (AC), antiplatelet (AP) use, and hematoma development. Methods We included 6800 patients from the WRAP-IT trial. To assess baseline and procedural characteristics associated with hematoma within the first 30 days postprocedure, a stepwise Cox regression model was implemented with minimal Akaike information criterion. Cox regressions were also used to evaluate AC/AP use and hematoma risk. Results The overall rate of hematoma was 2.2%. The model identified 11 baseline and procedural characteristics associated with hematoma risk. AC use (hazard ratio [HR]: 2.44, P < .001), lower body mass index (HR: 1.06, P < .001), and history of valve surgery (HR: 2.11, P < .001) were associated with the highest risk. AP use, male sex, history of coronary artery disease, existing pocket, history of nonischemic cardiomyopathy, number of previous cardiac implantable electronic device (CIED) procedures, procedure time, and lead revision were associated with moderate risk. Antithrombotic use was high overall (86%) and AC+AP use was highly predictive of hematoma risk. Regardless of AC status, AP use was associated with an almost doubling of risk vs no AP (HR = 1.85, P = .0006) in the general cohort. Interruption of AC was associated with the lowest hematoma risk (HR = 2.35) while heparin bridging (HR = 4.98) and AP use vs no AP use (HR = 1.85) was associated with the highest hematoma risk. Conclusion The results of this analysis highlight risk factors associated with the development of hematoma in patients undergoing CIED procedures and can inform antithrombotic management.
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Annetta MG, Bertoglio S, Biffi R, Brescia F, Giarretta I, Greca AL, Panocchia N, Passaro G, Perna F, Pinelli F, Pittiruti M, Prisco D, Sanna T, Scoppettuolo G. Management of antithrombotic treatment and bleeding disorders in patients requiring venous access devices: A systematic review and a GAVeCeLT consensus statement. J Vasc Access 2022; 23:660-671. [PMID: 35533088 DOI: 10.1177/11297298211072407] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Insertion of venous access devices (VAD) is usually considered a procedure with low risk of bleeding. Nonetheless, insertion of some devices is invasive enough to be associated with bleeding, especially in patients with previous coagulopathy or in treatment with antithrombotic drugs for cardiovascular disease. The current practices of platelet/plasma transfusion in coagulopathic patients and of temporary suspension of the antithrombotic treatment before VAD insertion are based on local policies and are often inadequately supported by evidence, since many of the clinical studies on this topic are not recent and are not of high quality. Furthermore, the protocols of antithrombotic treatment have changed during the last decade, after the introduction of new oral anticoagulant drugs. Though some guidelines address some of these issues in relation with specific procedures (port insertion, etc.), no evidence-based document covering all the aspects of this clinical problem is currently available. Thus, the Italian Group of Venous Access Devices (GAVeCeLT) has decided to develop a consensus on the management of antithrombotic treatment and bleeding disorders in patients requiring VADs. After a systematic review of the available evidence, the panel of the consensus (which included vascular access specialists, surgeons, intensivists, anesthetists, cardiologists, vascular medicine experts, nephrologists, infective disease specialists, and thrombotic disease specialists) has structured the final recommendations as detailed answers to three sets of questions: (1) which is an appropriate classification of VAD-related procedures based on the specific bleeding risk? (2) Which is the appropriate management of the patient with bleeding disorders candidate to VAD insertion/removal? (3) Which is the appropriate management of the patient on antithrombotic treatment candidate to VAD insertion/removal? Only statements reaching a complete agreement were included in the final recommendations, and all recommendations were offered in a clear and synthetic list, so to be easily translated into clinical practice.
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Affiliation(s)
| | | | - Roberto Biffi
- Surgical Unit, Istituto Europeo di Oncologia, Milano, Italy
| | - Fabrizio Brescia
- Anesthesia and Intensive Care, Centro di Riferimento Oncologico, Aviano, Italy
| | - Igor Giarretta
- Internal Medicine, University Hospital "A.Gemelli," Rome, Italy
| | - Antonio La Greca
- Vascular Access Team, University Hospital "A.Gemelli," Rome, Italy
| | - Nicola Panocchia
- Nephrology and Dialysis Unit, University Hospital "A.Gemelli," Rome, Italy
| | | | | | - Fulvio Pinelli
- Anesthesia and Intensive Care, Careggi University Hospital, Firenze, Italy
| | - Mauro Pittiruti
- Vascular Access Team, University Hospital "A.Gemelli," Rome, Italy
| | - Domenico Prisco
- Experimental and Clinical Medicine, Careggi University Hospital, Firenze, Italy
| | - Tommaso Sanna
- Cardiology, University Hospital 'A.Gemelli', Rome, Italy
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Demir M, Özbek M, Polat N, Aktan A, Yıldırım B, Argun L, İldırımlı K, Dursun L, Öztürk C, Güzel T, Kılıç R, Toprak N. A comparison of postoperative complications following cardiac implantable electronic device procedures in patients treated with antithrombotic drugs. Pacing Clin Electrophysiol 2022; 45:733-741. [DOI: 10.1111/pace.14517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/20/2022] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Muhammed Demir
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Mehmet Özbek
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Nihat Polat
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Adem Aktan
- Department of Cardiology Mardin Training and Research Hospital Mardin Turkey
| | - Bünyamin Yıldırım
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Lokman Argun
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Kamran İldırımlı
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Lezgin Dursun
- Division of Cardiology Bingöl State Hospital Bingöl Turkey
| | - Cansu Öztürk
- Department of Cardiology Gazi Yasargil Training and Research Hospital Diyarbakir Turkey
| | - Tuncay Güzel
- Department of Cardiology Gazi Yasargil Training and Research Hospital Diyarbakir Turkey
| | - Raif Kılıç
- Division of Cardiology Dagkapi Diyarlife Hospital Diyarbakir Turkey
| | - Nizamettin Toprak
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
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Calvo D, Pombo M, Benito B, Cano Ó, Fidalgo Andrés ML, Gómez-Bueno M, Jiménez Candil FJ, Lillo IM, Moriña-Vázquez P, Peñafiel-Verdú P, Rincón LM, Tolosana JM, Avanzas P, Berga Congost G, Boraita A, Bueno H, Calvo D, Campuzano R, Delgado V, Dos L, Ferreira-Gonzalez I, Gomez Doblas JJ, Pascual Figal D, Sambola A, Viana Tejedor A, Ferreiro JL, Alfonso F. Comments on the 2021 ESC guidelines on cardiac pacing and cardiac resynchronization therapy. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:370-374. [PMID: 35090861 DOI: 10.1016/j.rec.2021.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/02/2021] [Indexed: 06/14/2023]
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48
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Calvo D, Pombo M. Comentarios a la guía ESC 2021 sobre estimulación cardiaca y terapia de resincronización. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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49
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2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Translation of the document prepared by the Czech Society of Cardiology. COR ET VASA 2022. [DOI: 10.33678/cor.2022.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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50
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de Heide J, van der Graaf M, Holl MJ, Bhagwandien RE, Theuns DA, de Wit A, Zijlstra F, Szili-Torok T, Lenzen MJ, Yap SC. Pocket hematoma after pacemaker or defibrillator surgery: Direct oral anticoagulants versus vitamin K antagonists. IJC HEART & VASCULATURE 2022; 39:101005. [PMID: 35310376 PMCID: PMC8928071 DOI: 10.1016/j.ijcha.2022.101005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/25/2022] [Accepted: 03/12/2022] [Indexed: 11/05/2022]
Abstract
Background Direct oral anticoagulants (DOACs) are the preferred choice of oral anticoagulation in patients with atrial fibrillation (AF). Randomized trials have demonstrated the efficacy and safety of DOAC in patients undergoing a cardiac implantable electronic device procedure (CIED); however, there is limited real-world data. Objective To evaluate the outcome of patients undergoing an elective CIED procedure in a tertiary referral center with an interrupted DOAC or continued vitamin K antagonist (VKA) regimen. Methods This was a retrospective single-center study of consecutive patients with AF undergoing an elective CIED procedure between January 2016 and June 2019. The primary endpoint was a clinically significant pocket hematoma < 30 days after surgery. The secondary endpoint was any systemic thromboembolic complication < 30 days after surgery. Results Of a total of 1,033 elective CIED procedures, 283 procedures were performed in patients with AF using oral anticoagulation. One-third of the procedures were performed under DOAC (N = 81, 29%) and the remainder under VKA (N = 202, 71%). The DOAC group was younger, had less chronic renal disease, more paroxysmal AF and a lower HAS-BLED score. The VKA group more often underwent a generator change only in comparison to the DOAC group. Clinically significant pocket hematoma occurred in 5 patients (2.5%) in the VKA group and did not occur in the DOAC group (P = 0.33). There were no thromboembolic events reported. Conclusion In patients with AF undergoing an elective CIED procedure, the risk of a pocket hematoma and a systemic thromboembolic event is comparably low when using either continued VKA or interrupted DOAC.
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