Post-operative use of heparin increases morbidity of pacemaker implantation

A systematic review and meta-analysis of periprocedural bridging for patients with mechanical heart valves undergoing non-cardiac interventions

OBJECTIVE

To evaluate the safety and efficacy of perioperative bridging in patients with mechanical heart valves undergoing non-cardiac interventions.

MATERIALS AND METHODS

A systematic research using Medline, EMBASE, and Google Scholar was implemented corresponding to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement. Data from the eligible studies were obtained and meta-analyzed. Primary endpoints included major bleeding and thromboembolism. Secondary endpoints included minor bleeding, overall mortality, and overall bleeding (major and minor bleeding). We conducted a comparative analysis between bridging and non-bridging along with a sensitivity analysis for patients undergoing major and minor operations.

RESULTS

Fifteen studies comprised of 2305 patients (2453 bridging episodes) were included. Pooled major bleeding and thromboembolism rates were 3.85 % (95 % CI: 2.12-5.98) (I² = 69 %, p < 0.01) and 0.39 % (95 % CI: 0.00-1.41) (I² = 64 %, p < 0.01). Bridging versus non-bridging major bleeding, thromboembolism, and overall bleeding risk ratios (RR) were RR 2.05 (95 % CI: 0.98-4.28) (I² = 10 %, p = 0.34), RR 1.63 (95 % CI: 0.41-6.50) (I² = 0 %, p = 0.63) and RR 1.79 (95 % CI: 1.17-2.72) (I² = 55 %, p = 0.09) respectively. Subgroup analysis displayed major and minor operation thromboembolism and overall bleeding rates of 3.09 % (95 % CI: 0.78-6.43) (I² = 0 %, p = 0.89) versus 0.14 % (95 % CI: 0.00-1.40) (I² = 0 %, p = 0.93), test for subgroup differences (p < 0.01) and 17.37 % (95 % CI: 11.73-23.77) (I² = 0 %, p = 0.61) versus 28.18 % (95 % CI: 22.80-33.88) (I² = 0 %, p = 0.47), test for subgroup differences (p = 0.01) respectively.

CONCLUSION

Our analysis suggests that bridging may potentially put patients at an increased bleeding risk regarding overall bleeding rates, while failing to provide statistically significant benefits concerning thromboembolism and overall mortality compared to non-bridging. Limitations such as the mixed patient population don't allow for definite conclusions to be drawn warrantying further research through randomized controlled trials.

Is Implantable Cardioverter Defibrillator surgery in patients with an implanted left ventricular assist device safe under uninterrupted oral anticoagulation?

BACKGROUND

Implantable Cardioverter-Defibrillator (ICD) surgery in patients with implanted left ventricular assist devices (LVAD) is associated with an increased risk of bleeding complications because of the need to ensure that these patients are adequately anticoagulated. Our study aimed to evaluate the safety of our new strategy of uninterrupted oral anticoagulation compared to heparin-bridging during the surgical interval.

METHODS

Between 01/2009 and 01/2020, 116 patients with LVAD underwent ICD surgery. Since 01/2015, 60 patients were operated under continued sufficient oral anticoagulation with a vitamin k antagonist (VKA group). Fifty-six patients underwent a heparin-bridging regimen (heparin group). Demographics, perioperative data, complications, and mortality were analyzed.

RESULTS

Bleeding complications attributable to the surgical intervention occurred more often (19.6% vs. 10.0%, p=0.142) and at a higher rate of re-exploratory surgery (14.3 % vs. 5.0%, p=0.088) in the heparin group without reaching statistical significance. Moreover, the heparin group patients' postoperative total length of stay was 10 days longer. (17.8 ± 23.8 days vs. 8.3 ± 9.5 days, p=0.007). There were no procedure-related deaths, no thromboembolic events, and no LVAD-related thrombosis.

CONCLUSION

Our strategy of uninterrupted oral anticoagulation is safe and results in a reduction by more than half the number of days in hospital without an increase in adverse events.

Early Pacemaker Implantation after Transcatheter Aortic Valve Replacement: Impact of PlasmaBlade™ for Prevention of Device-Associated Bleeding Complications

Background and Objectives: Permanent pacemaker implantation (PPI) is frequently required following transcatheter aortic valve replacement (TAVR). Dual antiplatelet therapy (DAPT) or oral anticoagulation therapy (OAK) is often necessary in these patients since they are at higher risk of thromboembolic events due to TAVR implantation, high incidence of coronary artery diseases (CAD) with the necessity of coronary intervention, and high rate of atrial fibrillation with the need of stroke prevention. We sought to evaluate the safety, efficiency, and clinical outcomes of early PPI following TAVR using the PlasmaBlade™ (Medtronic Inc., Minneapolis, MN, USA) pulsed electron avalanche knife (PEAK) for bleeding control in patients under DAPT or OAK. Materials and Methods: This retrospective single-center study included patients who underwent PPI after transfemoral TAVR (TF) at our center between December 2015 and May 2020. All PPI were performed using the PlasmaBlade™ Device. Results: The overall PPI rate was 14.1% (83 of 587 patients; 82.5 ± 4.6 years; 45.8% male). The PPI procedures were used to treat high-grade atrioventricular block (81.9%), severe sinus node dysfunction (13.3%), and alternating bundle branch block (4.8%). At the time of the procedure, 35 (42.2%) patients received DAPT, and 48 (57.8%) patients received OAK (50% with vitamin K antagonist (VKA) and 50% with novel oral anticoagulants (NOAK)). One device-pocket hematoma treated conservatively occurred in a patient (1.2%) receiving NOAK. Two re-operations were necessary in patients due to immediate lead dislocation (2.4%). Conclusions: The results of this study illustrate that the use of PlasmaBlade™ for PPI in patients after a TAVR who require antithrombotic treatment is feasible and might result into lower rates of severe bleeding complications compared to rates reported in the literature. Use of the PlasmaBlade device may be considered in this specific group of patients because of their high risk of bleeding.

Wound haematoma following defibrillator implantation: incidence and predictors in the Shockless Implant Evaluation (SIMPLE) trial

Aims

Pocket haematoma is a common complication after defibrillator [implantable cardioverter defibrillator (ICD)] implantation, which is not only painful, but also increases the risk of device-related infection, and possibly embolic events. The present study seeks to evaluate the rate and predictors of clinically significant pocket haematoma.

Methods and results

This study included 2500 patients receiving an ICD in the SIMPLE trial. A clinically significant pocket haematoma was defined as a haematoma that required re-operation or interruption of oral anticoagulation (OAC) therapy. Clinically significant pocket haematoma occurred in 56 of 2500 patients (2.2%) of which 6 (10.7%) developed device-related infection. Patients who developed pocket haematoma were older (mean age 67.6 ± 8.8 years vs. 62.7 ± 11.6 years, P < 0.001), were more likely to have permanent atrial fibrillation (30.4 vs. 6.7%, P < 0.001) and a history of stroke (17.9 vs. 6.7%, P = 0.004), or were more likely to receive peri-operative OAC (50.0 vs. 28.4%, P < 0.001), unfractionated heparin (16.1 vs. 5.2%, P = 0.003), or low-molecular-weight heparin (37.5 vs. 17.5%, P < 0.001). Independent predictors of wound haematoma on multivariable analysis included the use of heparin bridging (OR 2.65, 95% CI 1.48-4.73, P = 0.001), sub-pectoral location of ICD (OR 2.00, 95% CI 1.12-3.57, P =0.020), previous stroke (OR 2.47, 95% CI 1.20-5.10, P = 0.015), an upgrade from permanent pacemaker (OR 2.52, 95% CI 1.07-5.94, P = 0.035), and older age (OR 1.03, 95% CI 1.00-1.06, P = 0.049).

Conclusion

Pocket haematoma remains an important complication of ICD implantation and is associated with a high risk of infection. Independent predictors of pocket haematoma include heparin bridging, prior stroke, sub-pectoral placement of ICD, older age, and upgrade from a pacemaker.

Management of Perioperative Anticoagulation for Device Implantation

Periprocedural management of anticoagulation for cardiac device implantation has evolved over the past 20 years. The traditional paradigm of vitamin K antagonist interruption with heparin bridging has now been shown to be less safe than continuation of vitamin K antagonists at therapeutic levels. Dual antiplatelet therapy during device implantation poses substantial risk but is often necessary. The safest dosing strategy for newer direct oral anticoagulants is still not clear.

Device implantation for patients on antiplatelets and anticoagulants: Use of suction drain

Background and objectives

Cardiovascular implantable electronic devices (CIED) are frequently implanted in patients on anti-thrombotic agents. Pocket hematomas are more likely to occur in these patients. The use of a sterile surgical drain in the pulse generator pocket site could prevent hematomas, but fear of infection precludes its use. The objective of the present study is to study the safety and efficacy of surgical drain in patients on antithrombotics undergoing CIED implantations.

Methods

This is a single-centre, retrospective study involving patients undergoing CIED implantations on antithrombotics (antiplatelets and anticoagulants) from August 2013 to July 2016. Patients with high risk of thromboembolism were continued on oral antithrombotics or were bridged with heparin after stopping oral antithrombotics. A sterile close wound suction drain was placed in device pockets following CIED implantations. Post procedure, pressure dressing was applied and removed after 12 h once the drain volume was less than 10 ml in 24 h.

Results

Sixty seven patients required surgical drain implantation. Major indications for antithrombotic use were presence of intracoronary stent, atrial fibrillation and mechanical valve replacements. The mean post-procedural hospital stay was 3 ± 0.9 days and mean overall drain was 16.6 ± 8.2 ml. At a mean follow up of 17.6 ± 8.2 months, one patient (1.4%) had pocket hematoma. There were no infections.

Conclusion

The use of a surgical drain in CIED implantation significantly reduces the risk of hematoma formation without increasing the risk of infection. Antithrombotic drugs can be safely continued at the time of implantation of cardiac devices.

How To Manage Oral Anticoagulation Periprocedurally During Ablations And Device Implantations

More than 150, 000 patients undergo ablation for atrial fibrillation (AF) each year.Current guidelines recommend oral anticoagulation in all patients undergoing AF ablation. A large number of patients undergoing cardiac implantable electronic devices (CIEDs) are on long-term oral anticoagulation. These patients are at increased risk for thromboembolism with interruption of oral anticoagulation. Due to the increased risk for bleeding complications during the procedure combined with the need to prevent thromboembolism, periprocedural management of anticoagulation in these patients can be challenging. In this article we review the current evidence for periprocedural management of oral anticoagulation in patients undergoing ablation and CIED implantation.

Periprocedural heparin bridging in patients receiving oral anticoagulation: a systematic review and meta-analysis

BACKGROUND

Periprocedural heparin bridging therapy aims to reduce the risk of thromboembolic events in patients requiring an interruption in their anticoagulation therapy for the purpose of an elective procedure. The efficacy and safety of heparin bridging therapy has not been well established.

OBJECTIVES

To compare through meta-analysis the effects of heparin bridging therapy on the risk of major bleeding and thromboembolic events of clinical significance among patients taking oral anticoagulants.

METHODS

We searched PubMed, EMBASE and the Cochrane library from January 2005 to July 2016. Studies were included if they reported clinical outcomes of patients receiving heparin bridging therapy during interruption of oral anticoagulant for operations. Data were pooled using random-effects modeling.

RESULTS

A total of 25 studies, including 6 randomized controlled trials and 19 observational studies, were finally included in this analysis. Among all the 35,944 patients, 10,313 patients were assigned as heparin bridging group, and the other 25,631 patients were non-heparin bridging group. Overall, compared with patients without bridging therapy, heparin bridging therapy increased the risk of major bleeding (OR = 3.23, 95%CI: 2.06-5.05), minor bleeding (OR = 1.52, 95%CI: 1.06-2.18) and overall bleeding (OR = 2.83, 95%CI: 1.86-4.30).While there was no significant difference in thromboembolic events (OR = 0.99,95%CI: 0.49-2.00), stroke or transient ischemic attack(OR = 1.45, 95%CI: 0.93-2.26,) or all-cause mortality (OR = 0.71, 95%CI: 0.31-1.65).

CONCLUSIONS

Heparin-bridging therapy increased the risk of major and minor bleeding without decreasing the risk of thromboembolic events and all cause death compared to non-heparin bridging.

Oral anticoagulation continuation compared with heparin bridging therapy among high risk patients undergoing implantation of cardiac rhythm devices

It was the objective of this study to systematically compare the effects of oral anticoagulation (OAC) with heparin bridging therapy among patients at high risk for thromboembolism undergoing implantation of cardiac rhythm devices. A systematic search of PubMed/MEDLINE, Ovid and Elsevier, and the Cochrane Library databases was conducted. Six trials that met our inclusion criteria were identified and included in the present study. The endpoints of this meta-analysis included pocket haematoma, severe haematoma requiring drainage/revision, thromboembolic events, and length of hospital stay. Data were expressed as odds ratios (ORs) and 95% confidence interval (CIs). There was a statistically significant reduction of pocket haematoma (OR 0.29, 95% CI: 0.17 to 0.49, p<0.00001) and haematoma drainage/revision (OR 0.15, 95%CI: 0.04 to 0.54, p=0.004), respectively, in the OAC continuation group versus the heparin bridging group. We did not detect any statistically sig- nificant differences of thromboembolic events (OR 0.48, 95%CI: 0.07 to 3.54, p=0.48) in the two groups. There was a trend that patients in bridging group had longer hospital stays. In conclusion, OAC continu- ation had a better risk-beneficial ratio and shorter length of hospital stay, and was more convenient to implement compared with heparin bridging therapy among patients at high risk for thromboembolism undergoing implantation of cardiac rhythm devices.

Oral anticoagulation management in patients with atrial fibrillation undergoing cardiac implantable electronic device implantation

Background

Oral anticoagulation (OAC) therapy is associated with increased periprocedural risks after cardiac implantable electronic device (CIED) implantation. Patterns of anticoagulation management involving non–vitamin K antagonist oral anticoagulants (NOACs) have not been characterized.

Hypothesis

Anticoagulation strategies and outcomes differ by anticoagulant type in patients undergoing CIED implantation.

Methods

Using the nationwide Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, we assessed how atrial fibrillation (AF) patients undergoing CIED implantation were cared for and their subsequent outcomes. Outcomes were compared by oral anticoagulant therapy (none, warfarin, or NOAC) as well as by anticoagulation interruption status.

Results

Among 9129 AF patients, 416 (5%) underwent CIED implantation during a median follow‐up of 30 months (interquartile range, 24–36). Of these, 60 (14%) had implantation on a NOAC. Relative to warfarin therapy, those on a NOAC were younger (70.5 years [range, 65–77.5 years] vs 77 years [range, 70–82 years]), had less valvular heart disease (15.0% vs 31.3%), higher creatinine clearance (67.3 [range, 59.7–99.0] vs 65.8 [range, 50.0–91.6]), were more likely to have persistent AF (26.7% vs 22.9%), and use concomitant aspirin (51.7% vs 35.2%). OAC therapy was commonly interrupted for CIED in 64% (n = 183 of 284) of warfarin patients and 65% (n = 39 of 60) of NOAC patients. Many interrupted patients received intravenous bridging anticoagulation: 33/183 (18%) interrupted warfarin and 4/39 (10%) interrupted NOAC patients. Thirty‐day periprocedure bleeding and stroke adverse events were infrequent.

Conclusions

Management of anticoagulation among AF patients undergoing CIED implantation is highly variable, with OAC being interrupted in more than half of both warfarin‐ and NOAC‐treated patients. Bleeding and stroke events were infrequent in both warfarin and NOAC‐treated patients.

Pacemaker Implantation in Elderly Patients: Safety of Various Regimens of Anticoagulant Therapy

OBJECTIVE

To study incidence of hemorrhagic complications after pacemaker implantation in elderly patients receiving antithrombotic therapy with warfarin or uninterrupted dabigatran.

METHODS

126 patients aged 83 [82; 85] years who receive continuous antithrombotic therapy after pacemaker implantation, were enrolled in the study. Adverse event data were collected during hospitalization and further 12 weeks.

RESULTS

95 subjects (75.4%) from general number of enrolled patients received elective anticoagulant warfarin therapy and 31 subjects (24.6%) were treated with dabigatran. All patients of dabigatran group received 220 mg/day skipping the last dose before a surgery and resumed the drug intake in 36-48 hours after it. Patients of warfarin group underwent surgery if INR was NMT 3; they didn't stop taking the drug for the duration of operation.No statistically significant differences of hematoma incidence were detected in dabigatran (incidence is 0.065, 95%CI (-0.02-0.15)) and warfarin (incidence is 0.05, 95%CI (0.006-0.01)) groups, p(Fisher)= 0.55. Three cases of nonfatal gastrointestinal bleeding (warfarin group) and 1 similar event in dabigatran group were detected during a follow-up (12 [6; 20] weeks): RR= 0.98 (warfarin group), p(Fisher)=0.68. No statistically significant difference of age, sex composition, history of IHD and diabetes was detected between groups by comparison of individual characteristics of patients whose surgeries were complicated/non-complicated by hematoma formation. Upon that, hematoma formation rate was significantly higher in patients with adjunctive pacemaker muscular fixation: 71.4% vs 31.9% (patients without hematomas), p(Fisher)= 0.045.

CONCLUSION

Incidence of hematoma formation after pacemaker implantation in patients > 75 years receiving warfarin or dabigatran, is the same as in general population of patients treated with anticoagulants. Adjunctive pacemaker muscular fixation is a significant risk factor of hematoma formation.

Incidence, predictors and outcomes of hematoma after ICD implantation: An analysis of a nationwide database of 85,276 patients

BACKGROUND

Pocket hematoma is one of the most common complications following cardiac device implantation. This study examined the impact of this complication on in-hospital outcomes following Implantable Cardioverter Defibrillator (ICD) implantation.

METHODS

Data from Nationwide Inpatient Sample (NIS) 2010 was queried to identify all primary implantations of ICDs and Cardiac Resynchronization Therapy Defibrillators (CRT-D) during the year 2010 using ICD-9 codes. We then identified the patients who experienced a procedure related hematoma during the hospital stay. We compared the outcomes of the patients with and without a hematoma complication. All analyses were performed using SPSS 20 complex samples using appropriate weights to adjust for the complex sampling design of the national database.

RESULTS

Out of a total of 85,276 primary ICD implantations in the year 2010, 2233 (2.6% of the implantations) were complicated by a hematoma. Increased age (p < 0.001), and comorbidities such as congestive heart failure (odds ratio (OR) - 1.86, p < 0.001), coagulopathy (OR - 2.3, p < 0.001) and renal failure (OR - 1.52, p < 0.001) were associated with an increased risk of pocket hematoma formation. Patients who developed a hematoma had a longer hospitalization (9.1 days versus 5.5 days, p < 0.001) and higher in-hospital costs ($56,545 versus $47,015, p < 0.001) compared to patients who did not have a hematoma. Overall mortality associated with ICD implantation was low (0.6%), and hematoma formation did not adversely affect mortality (0.6% versus 0.4%, p = 0.63).

CONCLUSION

Hematoma occurs infrequently after ICD implantation, however, it adversely impacts the cost of procedure and length of stay.

Clinically Significant Pocket Hematoma Increases Long-Term Risk of Device Infection: BRUISE CONTROL INFECTION Study

BACKGROUND

The BRUISE CONTROL trial (Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial) demonstrated that a strategy of continued warfarin during cardiac implantable electronic device surgery was safe and reduced the incidence of clinically significant pocket hematoma (CSH). CSH was defined as a post-procedure hematoma requiring further surgery and/or resulting in prolongation of hospitalization of at least 24 h, and/or requiring interruption of anticoagulation. Previous studies have inconsistently associated hematoma with the subsequent development of device infection; reasons include the retrospective nature of many studies, lack of endpoint adjudication, and differing subjective definitions of hematoma.

OBJECTIVES

The BRUISE CONTROL INFECTION (Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial Extended Follow-Up for Infection) prospectively examined the association between CSH and subsequent device infection.

METHODS

The study included 659 patients with a primary outcome of device-related infection requiring hospitalization, defined as 1 or more of the following: pocket infection; endocarditis; and bloodstream infection. Outcomes were verified by a blinded adjudication committee. Multivariable analysis was performed to identify predictors of infection.

RESULTS

The overall 1-year device-related infection rate was 2.4% (16 of 659). Infection occurred in 11% of patients (7 of 66) with previous CSH and in 1.5% (9 of 593) without CSH. CSH was the only independent predictor and was associated with a >7-fold increased risk of infection (hazard ratio: 7.7; 95% confidence interval: 2.9 to 20.5; p < 0.0001). Empiric antibiotics upon development of hematoma did not reduce long-term infection risk.

CONCLUSIONS

CSH is associated with a significantly increased risk of infection requiring hospitalization within 1 year following cardiac implantable electronic device surgery. Strategies aimed at reducing hematomas may decrease the long-term risk of infection. (Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial [BRUISE CONTROL]; NCT00800137).

Strategy of continued vs interrupted novel oral anticoagulant at time of device surgery in patients with moderate to high risk of arterial thromboembolic events: The BRUISE CONTROL-2 trial

BACKGROUND

Patients who require perioperative anticoagulation during cardiac implantable electronic device surgery are at increased risk for bleeding complications. The BRUISE CONTROL trial demonstrated that continuing warfarin was safer than heparin bridging, reducing the incidence of clinically significant pocket hematoma. Novel oral anticoagulants are being increasingly prescribed in place of warfarin. The best perioperative management of these new anticoagulants is unknown.

METHODS/DESIGN

A randomized controlled trial to investigate whether a strategy of continued vs interrupted novel oral anticoagulant (dabigatran, rivaroxaban, or apixaban) at the time of device surgery, in patients with moderate to high risk of arterial thromboembolic events, reduces the incidence of clinically significant hematoma (defined as a hematoma requiring reoperation and/or resulting in prolongation of hospitalization, and/or requiring interruption of anticoagulation). The secondary outcomes include components of the primary outcome, composite of all other major perioperative bleeding events, thromboembolic events, all-cause mortality, cost-effectiveness, patient quality of life, perioperative pain, and satisfaction. Planned analyses include descriptive statistics of all baseline variables. For the primary outcome, interrupted vs continued novel oral anticoagulant arms will be compared using the χ(2) test. If any clinically significant differences are identified, a logistic regression analysis will be conducted. Quality of life will be assessed using EuroQol-5D, and perioperative pain using a visual analog scale.

DISCUSSION

BRUISE CONTROL-2 is a randomized trial evaluating the best strategy to manage novel oral anticoagulants at the time of device surgery. We hypothesize that device surgery can be performed safely without interruption of these medications.

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

PURPOSE

Implantation of permanent pacemakers (PPMs) or implantable cardiac defibrillators (ICDs) may be complicated by the development of pocket hematomas. Current practice guidelines provide little guidance to clinicians about the preferred strategy for chronic oral anticoagulation (OAC). The purpose of this study was to examine the frequency and clinical significance of pocket hematoma among patients receiving uninterrupted OAC during cardiac device implantation.

METHODS

This was a retrospective cohort study of adult patients undergoing cardiac device implantation between January 1, 2011, and December 31, 2012, at an academic teaching hospital. Medical records were reviewed for demographics, comorbidities, and medications. The primary outcome was development of pocket hematomas within 30 days of device implantation. Clinical significance was based on the need for additional intervention. Data were assessed using descriptive statistics, logistic regression, and chi-square tests.

RESULTS

The final cohort included 380 patients. The median age was 68.4 years, and 56.6% were male. Cardiovascular comorbidities were common. Among 80 patients receiving uninterrupted OAC, 71.3% were taking warfarin, 11.2% rivaroxaban, and 17.5% dabigatran. The incidence of pocket hematomas for the entire cohort was 9.7%, of which 1.3% were clinically significant. Pocket hematoma occurred in 21.4% of patients continued on OAC versus 7.7% of those not anticoagulated (P = .001). Pocket hematoma was more common among those receiving ICDs than PPMs (18.5% vs 5.7%, respectively; P < .001).

CONCLUSIONS

Continuing chronic OAC increased pocket hematoma formation but most were clinically insignificant. Pocket hematoma occurred irrespective of the oral anticoagulant drug used, but additional study is needed to determine comparative risks among the drugs.

Safety of anticoagulation with uninterrupted warfarin vs. interrupted dabigatran in patients requiring an implantable cardiac device

BACKGROUND

The optimal strategy of peri-procedural anticoagulation in patients undergoing permanent cardiac device implantation is controversial. Our objective was to compare the major bleeding and thromboembolic complications in patients managed with uninterrupted warfarin (UW) vs. interrupted dabigatran (ID) during permanent pacemaker (PPM) or implantable cardioverter defibrillators (ICD) implantation.

METHODS

A retrospective cohort study of all eligible patients from July 2011 through January 2012 was performed. UW was defined as patients who had maintained a therapeutic international normalized ratio (INR) on the day of the procedure. ID was defined as stopping dabigatran ≥12 hours prior to the procedure and then resuming after implantation. Major bleeding events included hemothorax, hemopericardium, intracranial hemorrhage, gastrointestinal bleed, epistaxis, or pocket hematoma requiring surgical intervention. Thromboembolic complications included stroke, transient ischemic attack, deep venous thrombosis, pulmonary embolism, or arterial embolism.

RESULTS

Of the 133 patients (73.4±11.0 years; 91 males) in the study, 86 received UW and 47 received ID. One (1.2%) patient in the UW group sustained hemopericardium perioperatively and died. In comparison, the ID patients had no complications. As compared to the ID group, the UW group had a higher median CHADS2 score (2 vs. 3, P=0.04) and incidence of Grade 1 pocket hematoma (0% vs. 7%, P=0.09). Neither group developed any thromboembolic complications.

CONCLUSIONS

Major bleeding rates were similar among UW and ID groups. Perioperative ID appears to be a safe anticoagulation strategy for patients undergoing PPM or ICD implantation.

Predictors of pocket hematoma in patients on antithrombotic therapy undergoing cardiac rhythm device implantation: insights from the FinPAC trial

BACKGROUND

The FinPAC trial showed that the strategy of uninterrupted oral anticoagulation (OAC) was non-inferior to interrupted OAC for the primary outcome of bleeding and thromboembolic complications in patients undergoing cardiac rhythm management device (CRMD) implantation.

METHODS

We conducted a post hoc analysis of the FinPAC data to explore the incidence and predictors of significant (> 100 cm(2)) pocket hematoma after CRMD implantation among the study population (n = 447). A total of 213 patients were on OAC, 128 were on aspirin, and 106 on no antithrombotic therapy.

RESULTS

The incidence of significant pocket hematoma during hospital stay was significantly higher among patients using OAC (5.6%) and aspirin (5.5%) than in those with no antithrombotic medications (0.9%), but only one patient (0.8%) in the aspirin group needed revision of hematoma. Two patients (0.9%) in the OAC group and one (0.8%) in the aspirin group needed blood products. In multivariable regression analysis, no pre- procedural features predicted the significant hematoma in any of the groups.

CONCLUSIONS

Clinically significant pocket hematoma is a rare complication after CRMD implantation in patients with ongoing therapeutic OAC. The incidence of significant pocket hematoma formation is similar in patients using OAC and those using aspirin.

Cardiac rhythm device surgery with uninterrupted oral anticoagulation

Current guidelines recommend interrupting anticoagulation and bridging therapy with heparin or low-molecular-weight heparin for cardiac rhythm device surgeries in patients with high thrombotic risk. However, there are some studies that suggest continuing warfarin may be safe. The study by Birnie et al. investigates this important clinical question in a randomized controlled trial setting. They randomly assigned 681 patients with high thrombotic risk (5% or more per year), in 18 centers, to receive either stopping warfarin combined with heparin bridging (standard of care) or continued uninterrupted warfarin therapy for cardiac rhythm device surgery. The trial was terminated after a second prespecified interim analysis by the data and safety monitoring board. Clinically significant device-pocket hematoma was noted in 12 out of 343 patients (3.5%) in the uninterrupted warfarin group, compared with 54 out of 338 (16.0%) in the heparin-bridging group (relative risk: 0.19; 95% CI: 0.10-0.36; p < 0.001). Uninterrupted warfarin was associated with better patient satisfaction, and there was no significant difference in thromboembolic or surgical complications between the two groups. These results demonstrate that device surgeries can be safely performed with continued warfarin, and bridging with heparin is associated with high risk of device-pocket hematoma.

Cardiovascular implantable electronic device implantation with uninterrupted dabigatran: comparison to uninterrupted warfarin

BACKGROUND

While continuation of oral anticoagulation (OAC) with warfarin may be preferable to interruption and bridging with heparin for patients undergoing cardiovascular implantable electronic device (CIED) implantation, it is uncertain whether the same strategy can be safely used with dabigatran.

OBJECTIVE AND METHODS

To determine the risk of bleeding and thromboembolic complications associated with uninterrupted OAC during CIED implantation, replacement, or revision, the outcomes of patients receiving uninterrupted dabigatran (D) were compared to those receiving warfarin (W).

RESULTS

D was administered the day of CIED implant in 48 patients (age 66 ± 12.4 years, 13 F and 35 M, 21 ICDs and 27 PMs), including new implant in 25 patients, replacement in 14 patients, and replacement plus lead revision in 9 patients. D was held the morning of the procedure in 14 patients (age 70 ± 11 years, 4 F and 10 M, 5 ICDs and 9 PMs). W was continued in 195 patients (age 60 ± 14.4 years, 54 F, and 141 M), including new implant in 122 patients, replacement in 33 patients, and replacement plus lead revision or upgrade in 40 patients. Bleeding complications occurred in 1 of 48 patients (2.1%) with uninterrupted dabigatran (a late pericardial effusion), 0 of 14 with interrupted D, and 9 of 195 patients (4.6%) on W (9 pocket hematomas), P = 0.69. Fifty percent of bleeding complications were associated with concomitant antiplatelet medications.

CONCLUSIONS

The incidence of bleeding complications is similar during CIED implantation with uninterrupted D or W. The risks are higher when OAC is combined with antiplatelet drugs.

Pacemaker or defibrillator surgery without interruption of anticoagulation

BACKGROUND

Many patients requiring pacemaker or implantable cardioverter-defibrillator (ICD) surgery are taking warfarin. For patients at high risk for thromboembolic events, guidelines recommend bridging therapy with heparin; however, case series suggest that it may be safe to perform surgery without interrupting warfarin treatment. There have been few results from clinical trials to support the safety and efficacy of this approach.

METHODS

We randomly assigned patients with an annual risk of thromboembolic events of 5% or more to continued warfarin treatment or to bridging therapy with heparin. The primary outcome was clinically significant device-pocket hematoma, which was defined as device-pocket hematoma that necessitated prolonged hospitalization, interruption of anticoagulation therapy, or further surgery (e.g., hematoma evacuation).

RESULTS

The data and safety monitoring board recommended termination of the trial after the second prespecified interim analysis. Clinically significant device-pocket hematoma occurred in 12 of 343 patients (3.5%) in the continued-warfarin group, as compared with 54 of 338 (16.0%) in the heparin-bridging group (relative risk, 0.19; 95% confidence interval, 0.10 to 0.36; P<0.001). Major surgical and thromboembolic complications were rare and did not differ significantly between the study groups. They included one episode of cardiac tamponade and one myocardial infarction in the heparin-bridging group and one stroke and one transient ischemic attack in the continued-warfarin group.

CONCLUSIONS

As compared with bridging therapy with heparin, a strategy of continued warfarin treatment at the time of pacemaker or ICD surgery markedly reduced the incidence of clinically significant device-pocket hematoma. (Funded by the Canadian Institutes of Health Research and the Ministry of Health and Long-Term Care of Ontario; BRUISE CONTROL ClinicalTrials.gov number, NCT00800137.).

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

The perioperative bleeding risk associated with therapeutic anticoagulation at cardiac implantable electronic device implantation has previously been demonstrated to vary by the specific anticoagulant used. Although uninterrupted anticoagulation with warfarin appears to be safe, heparin products have been shown to increase the risk of perioperative bleeding. However, the risk associated with cardiac implantable electronic device implantation with anticoagulation using dabigatran, a novel oral direct thrombin inhibitor, is not known. We performed a prospective observational study of patients receiving dabigatran for anticoagulation who underwent cardiac implantable electronic device implantation from June 2011 through May 2012. The study end points included thromboembolic and bleeding complications within 30 days of surgery. Major bleeding complications were defined as bleeding requiring surgical intervention, prolongation of hospitalization, and discontinuation of the anticoagulant or transfusion of blood products within 30 days of surgery. Minor bleeding complications included the development of a hematoma not requiring additional intervention. The thrombotic end points included stroke, transient ischemic attack, myocardial infarction, pulmonary embolism, and deep vein thrombosis. A total of 25 patients were identified for inclusion. During the index hospitalization, no thromboembolic or bleeding complications developed. No major bleeding complications occurred within 30 days of surgery. One minor bleeding event (4%) occurred within 30 days of surgery in 1 patient who was also receiving dual antiplatelet therapy. In conclusion, although no thromboembolic or major bleeding events were observed, additional studies are required to define the optimal antithrombotic management in the perioperative period.

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

BACKGROUND

In patients with a high risk for stroke and having invasive procedures with a high risk for bleeding it is unclear how anticoagulant therapy should be managed.

METHODS

We reviewed data from all patients with mechanical heart valves, who had elective insertion or replacement of pacemaker or implantable cardioverter defibrillator (ICD) during the past 8years at our hospital. Data on anticoagulant treatment, pocket hematoma and thromboembolic complications were captured.

RESULTS

Of the 111 patients reviewed, 68 (61%) had a mechanical valve in the mitral position with or without other valves replaced and 43 (39%) had a mechanical valve only in the aortic position. Fifty-nine (53%) were undergoing replacement for their device. Six patients received a tapered warfarin regimen and 102 received preoperative bridging anticoagulation of whom 12 also received postoperative bridging. One stroke occurred 40days after pacemaker replacement in a patient with mitral mechanical valve and without postoperative bridging. Six patients (5.5%) developed pocket hematoma without a significant association to postoperative bridging, type of mechanical valve or to type of device. Predictors for pocket hematoma appeared to be replacement surgery (odds ratio 12.5; 95% confidence interval [CI], 0.69-228) and an international normalized ratio of 1.5 or higher on the day of surgery (odds ratio 8.4; 95% CI, 0.96-68.1).

CONCLUSION

We found a low risk for stroke in the absence of postoperative bridging. For patients with device replacement surgery reversal of the anticoagulant effect at the time of procedure might reduce the risk for pocket hematoma, but this requires prospective evaluation including the risk of thromboembolism.

Antithrombotic or anti-platelet agents in patients undergoing permanent pacemaker implantation

Background and Objectives

The growing implantations of electrophysiological devices in the context of increasing rates of chronic antithrombotic therapy in cardiovascular disease patients underscore the importance of an effective periprocedural prophylactic strategy for prevention of bleeding complications. We assessed the risk of significant bleeding complications in patients receiving anti-platelet agents or anticoagulants at the time of permanent pacemaker (PPM) implantation.

Subjects and Methods

We reviewed bleeding complications in patients undergoing PPM implantation. The use of aspirin or clopidogrel was defined as having taking drugs within 5 days of the procedure and warfarin was changed to heparin before the procedure. A significant bleeding complication was defined as a bleeding incident requiring pocket exploration or blood transfusion.

Results

Permanent pacemaker implantations were performed in 164 men and 96 women. The mean patient age was 73±11 years old. Among the 260 patients, 14 patients took warfarin (in all of them, warfarin was changed to heparin at least 3 days before procedure), 54 patients took aspirin, 4 patients took clopidogrel, and 25 patients took both. Significant bleeding complications occurred in 8 patients (3.1%), all of them were patients with heparin bridging (p<0.0001). Heparin bridging markedly increased the length of required hospital stay when compare with other groups and the 4 patients (1.5%) that underwent the pocket revision for treatment of hematoma.

Conclusion

This study suggests that hematoma formation after PPM implantation was rare, even among those who had taken the anti-platelet agents. The significant bleeding complications frequently occurred in patients with heparin bridging therapy. Therefore, heparin bridging therapy was deemed as high risk for significant bleeding complication in PPM implantation.

Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates

BACKGROUND

Periprocedural bridging with unfractionated heparin or low-molecular-weight heparin aims to reduce the risk of thromboembolic events in patients receiving long-term vitamin K antagonists. Optimal periprocedural anticoagulation has not been established.

METHODS AND RESULTS

MEDLINE, EMBASE, and Cochrane databases (2001-2010) were searched for English-language studies including patients receiving heparin bridging during interruption of vitamin K antagonists for elective procedures. Data were independently collected by 2 investigators (κ=0.90). The final review included 34 studies with 1 randomized trial. Thromboembolic events occurred in 73 of 7118 bridged patients (pooled incidence, 0.9%; 95% confidence interval [CI], 0.0.0-3.4) and 32 of 5160 nonbridged patients (pooled incidence, 0.6%; 95% CI, 0.0-1.2). There was no difference in the risk of thromboembolic events in 8 studies comparing bridged and nonbridged groups (odds ratio, 0.80; 95% CI, 0.42-1.54). Bridging was associated with an increased risk of overall bleeding in 13 studies (odds ratio, 5.40; 95% CI, 3.00-9.74) and major bleeding in 5 studies (odds ratio, 3.60; 95% CI, 1.52-8.50) comparing bridged and nonbridged patients. There was no difference in thromboembolic events (odds ratio, 0.30; 95% CI, 0.04-2.09) but an increased risk of overall bleeding (odds ratio, 2.28; 95% CI, 1.27-4.08) with full versus prophylactic/intermediate-dose low-molecular-weight heparin bridging. Low-thromboembolic-risk and/or non-vitamin K antagonist patient groups were used for comparison. Study quality was poor with heterogeneity for some analyses.

CONCLUSIONS

Vitamin K antagonist-treated patients receiving periprocedural heparin bridging appear to be at increased risk of overall and major bleeding and at similar risk of thromboembolic events compared to nonbridged patients. Randomized trials are needed to define the role of periprocedural heparin bridging.

Managing anticoagulation in patients receiving implantable cardiac devices

A substantial proportion of patients who undergo cardiac rhythm device implantation receive anticoagulation to prevent thromboembolism. Many patients have coexisting cardiovascular diseases treated with antiplatelet therapy. Anticoagulation may increase the risk of hemorrhagic complication, while withdrawal of anticoagulation may increase thromboembolic risk. In this article, we review and describe the available evidence, in order to inform best practice .

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

BACKGROUND

Many patients receiving cardiac rhythm devices have conditions requiring antiplatelet (AP) and/or anticoagulant (AC) therapy. Current guidelines recommend a heparin-bridging strategy (HBS) for anticoagulated patients with moderate/high risk for thrombosis. Several studies reported lower bleeding risk with continued oral anticoagulation rather than HBS. The best strategy for perioperative management of patients on AP therapy is less clear. The present study was designed as a meta-analysis of device implantation-associated bleeding complications using different AC/AP therapies.

METHODS AND RESULTS

PubMed and Cochrane Database searches identified articles based on design, outcomes, and available data. Device recipients were grouped as follows: no therapy, aspirin only, AC held, AC continued, dual AP, and HBS. The primary outcome was defined as a bleeding complication including hematoma, transfusion, or prolonged hospital stay. Thirteen articles were identified for analysis including 5978 patients. The combined incidence of bleeding complications was 274 of 5978 (4.6%), ranging from 2.2% (no therapy) to 14.6% (HBS). The estimated odds of bleeding were increased by 8.3 (95% CI, 5.5-12.9) times in the HBS group, 5.0 (95% CI, 3.0-8.3) for dual AP therapy, 1.7 (95% CI, 1.0-3.1) for AC held, 1.6 (95% CI, 0.9-2.6) for AC continued, and 1.5 (95% CI, 0.9-2.3) for aspirin only relative to the no therapy group. HBS significantly increased bleeding events compared with holding or continuing AC. Continuing AC did not increase bleeding events compared with no therapy.

CONCLUSIONS

Continuing AC appears safer than HBS for device implantation. Dual AP therapy but not continuing AC carries a significant risk of bleeding.

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

Long-term anticoagulation with a vitamin K antagonist (VKA) or the new agent dabigatran is recommended to decrease stroke risk in patients with atrial fibrillation. When patients with atrial fibrillation undergo initiation or interruption of VKA therapy, or experience an isolated subtherapeutic international normalized ratio (INR), bridge therapy with a parenteral anticoagulant may be considered. To describe the literature for anticoagulation bridge therapy in patients with atrial fibrillation, we conducted a MEDLINE search (1966-February 2011) of the English-language literature to identify related studies. Ongoing clinical trials were identified through a search of the ClinicalTrials.gov registry. Major national and international guidelines were gathered and evaluated. Additional literature was obtained through review of relevant references of the identified articles. Bridging is not supported by guidelines or clinical trials for patients starting VKA therapy for atrial fibrillation. A subtherapeutic INR value during long-term VKA therapy may be associated with increased thromboembolic events, but the benefit of bridging has not been demonstrated. When VKA therapy is interrupted for procedures, retrospective and cohort data suggest that the decision to bridge should be based on a patient's thromboembolic and bleeding risks associated with the procedure. Typically, it is recommended to use bridge therapy in patients with atrial fibrillation at high risk for thromboembolism, but the benefit of bridging is less clear in patients at low risk. Not all procedures necessitate anticoagulation interruption. Recent trials suggest that VKAs can be continued when patients are undergoing cardiac device procedures and some types of radiofrequency ablation. Several clinical trials are ongoing that will provide more definitive guidance for perioperative anticoagulation management of patients with atrial fibrillation. Patients taking dabigatran are unlikely to require bridge therapy because of a predictable anticoagulant effect and rapid onset of action. However, evidence for optimal perioperative management of dabigatran is needed.

Implantation of cardiac rhythm devices during concomitant anticoagulation or antiplatelet therapy

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

Bleeding complications after pacemaker or cardioverter-defibrillator implantation in patients receiving dual antiplatelet therapy: Results of a prospective, two-centre registry

Introduction. The aim of the study was to define the prevalence of bleeding events in patients treated with dual antiplatelet therapy (DAT) in comparison with patients receiving only acetylsalicylic acid (ASA).Methods. Prospective two-centre registry of all first implantations of pacemakers, cardioverter-defibrillators and cardiac resynchronisation therapy units in patients receiving ASA (n=194) or DAT (n=53).Results. Bleeding complications were detected in 27 (16.2%) patients in the ASA group and in 13 (24.5%) in the DAT group. There was no significant difference in the overall number of complications between the patients receiving ASA or DAT, although there was a trend towards a higher incidence of overall complication rates in the DAT group (p=0.0637). The incidence of major complications (requiring blood transfusion or surgical intervention or prolonging hospital stay) was low (3.6%), and similar in both groups (3.6 and 3.8% respectively, ns). The rate of minor complications (subcutaneous haematomas) was greater in the DAT group (p=0.015).Conclusions. Treatment with DAT does not increase the risk of major bleeding complications as a result of device implantation; however, minor complications are significantly more frequent. Our results suggest that DAT could be continued in patients undergoing device implantation with a moderate risk of bleeding complications. (Neth Heart J 2010;18:230-5.).

Peri-procedural anticoagulation and the incidence of haematoma formation after permanent pacemaker implantation in the elderly

BACKGROUND

Haematoma formation is a recognised complication after permanent pacemaker (PPM) implantation. The contribution of peri-procedural anticoagulation to the risk of haematoma formation is unclear.

METHOD

The records of 518 consecutive patients, mean age 76.9±9.8 years, receiving their first PPM (2004-2007) in a single tertiary referral centre were reviewed. Follow-up was complete for 506 patients (97.7%) up to six weeks. Haematomas were diagnosed clinically, and further subdivided according to the need for evacuation.

RESULTS

There were 27 instances of haematoma formation in 25 patients (4.9%) with 19 requiring drainage or evacuation. Twenty-one of the 25 patients who developed a haematoma had stopped warfarin and received bridging therapeutic anticoagulation pre- and post-PPM. The incidence of haematoma was significantly greater in those receiving peri-operative therapeutic anticoagulation (26.9% vs 0.9%, p<0.001), but was unaffected by the use of anti-platelet therapy. Most haematomas developed in patients whose heparin was recommenced within 24 hours of implantation. The development of haematoma post-PPM increased median hospital stay significantly (p<0.001). The main indication for anticoagulation in these patients was atrial fibrillation (79.5%) and most of these patients had a low to intermediate risk of peri-procedural thromboembolic events.

CONCLUSION

Peri-operative therapeutic anticoagulation is associated with more than 25-fold increase in haematoma formation post-pacemaker implantation. The risk-benefit ratio of therapeutic anticoagulation should be carefully considered, particularly in patients with a low risk of thromboembolic events.

[Progress in cardiac pacing]

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

Perioperative management of anticoagulation during device implantation-the UK perspective

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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