Is Antiarrhythmia Device Implantation Safe Under Dual Antiplatelet Therapy?

Subcutaneous versus Transvenous Implantable Cardioverter Defibrillator in Patients with End-Stage Renal Disease Requiring Dialysis: Extended Long-Term Retrospective Multicenter Follow-Up

BACKGROUND

Implantable cardioverter defibrillators (ICD) prevent sudden cardiac death (SCD). Patients with end-stage renal disease (ESRD) requiring dialysis are at a very high risk of infection from cardiac implantable electronic device (CIED) implantation as well as mortality. In the present study, we compared the long-term complications and outcomes between subcutaneous ICD (S-ICD) and transvenous ICD (TV-ICD) recipients.

METHODS

In this retrospective analysis, we analyzed a total of 43 patients with ESRD requiring dialysis who received either a prophylactic S-ICD (26 patients) or a single right ventricular lead TV-ICD (17 patients) at seven experienced centers in Germany. Follow-up was performed bi-annually, at the end of which the data concerning comorbidities and, if applicable, reason for death were checked and confirmed with patients' general practitioner, nephrologist and cardiologist.

RESULTS

The median follow up duration was 95.6 months (range 42.8-126.3 months). Baseline characteristics were without noteworthy significant differences between groups. During follow-up (FU), there were significantly more device-associated infections (HR 8.72, 95% confidence interval (CI), 1.18 to 12.85, p < 0.05) and device-associated hospitalizations (HR 10.20, 95% CI 1.22 to 84.61, p < 0.001), as well as a higher cardiovascular mortality (HR 9.17, 95% CI 1.12 to 8.33, p < 0.05), in the TV-ICD group. The number of patients requiring hospitalization for any reason was significantly higher in the TV-ICD group (HR 2.59, 95% CI 1.12 to 6.41, p < 0.05). There was no significant difference in overall mortality (HR 1.92, 95% CI 0.96 to 6.15, p = 0.274).

CONCLUSIONS

Our data suggest that, in this extended follow-up in seriously compromised renal patients on dialysis, the S-ICD patients have statistically fewer device infections and hospitalizations as well as lower cardiac mortality compared with the TV-ICD cohort.

Management of Device Infections

The rate of cardiac implantable electronic device (CIED) infection has increased disproportionately to the rate of implantation. Expanded indications for CIED implantation combined with a sicker patient population contribute to this increased rate. Device-related infections are most commonly due to perioperative contamination, and infection risk increases in conjunction with procedural complexity. Early pocket re-exploration and upgrade procedures confer a higher infectious risk. Confirmed CIED infection requires prompt removal of the CIED system combined with antimicrobial therapy. Understanding the risks of CIED infection and using preventive measures are critical. It is hoped that emerging technologies will mitigate CIED infection rates.

Pocket haematoma after cardiac electronic device implantation in patients receiving antiplatelet and anticoagulant treatment: a single-centre experience

Objective In modern cardiology practice, implantation of cardiac electronic devices in patients taking anticoagulant or antiplatelet therapy is a common clinical scenario. Bleeding complications are of particular concern in this patient population and pocket haematoma is one of the most frequent complications. We sought to determine the relationship between periprocedural antiplatelet/anticoagulant therapy and pocket haematoma formation in patients undergoing cardiac implantable electronic device (CIED) implantation. Methods We conducted a retrospective study including 232 consecutive patients undergoing CIED implantation in the department of cardiology of the Medipol University Hospital. Patients were divided into six groups: clopidogrel group (n = 12), acetylsalicylic acid (ASA) group (n = 73), ASA + clopidogrel group (n = 29), warfarin group (n = 34), warfarin + ASA group (n = 21) and no antiplatelet-anticoagulant therapy group as the control group (n = 63). CIED implantations were stratified under four subtitles including implantable cardioverter/defibrillator (ICD), cardiac resynchronization therapy (CRT), permanent pacemaker and the last group as either device upgrade or generator replacement. Results The mean age of the patients was 63 ± 14 years and 140 patients were male (60.3%). A pocket haematoma was documented in 6 of 232 patients (2.6%). None of the patients with pocket haematoma needed pocket exploration or blood transfusion. The type of the device did not have a significant effect on pocket haematoma incidence (P = 0.250). Univariate logistic regression showed that platelet level and ASA plus clopidogrel use were significantly associated with haematoma frequency after CIED implantations, respectively (OR: 0.977, CI 95% [0.958-0.996]; OR: 16.080, CI 95% [2.801-92.306]). Multivariate analysis revealed that dual antiplatelet treatment (β = 3.016, P = 0.002, OR: 2.410, 95% CI [3.042-136.943]) and baseline platelet level (β = -0.027, p:0.025, OR: 0.974, 95% CI [0.951-0.997]) were independent risk factors for pocket haematoma formation. Conclusion Dual antiplatelet therapy and low platelet levels significantly increased the risk of pocket haematoma formation in patients undergoing CIED implantations.

[Safety of device implantation under antipatelet therapy with ticagrelor: About 20 cases]

INTRODUCTION

Management of antiplatelet therapy at the time of device implantation remains controversial. This study aimed to assess the risk of bleeding complications in patients receiving ticagrelor at the time of cardiac device surgery.

METHODS

We performed a multicentre (n=4), retrospective study from January 2015 to January 2016. The survey included all patients (pts) treated with ticagrelor before undergoing pacemaker, implantable cardioverter-defibrillator (ICD) implantation or generator replacement. We report hemorrhagic post-procedural complications at 1 month. A significant bleeding complication was defined as pocket hematoma requiring a surgical evacuation or prolonged hospitalization, hemothorax, pericardial effusion, or tamponade.

RESULTS

A total of 20 patients underwent a permanent pacemaker or ICD implantation while taking a combination of antipatelet therapy with ticagrelor and aspirin. The mean age of the patients was 65±9 years, 95% were male, 25% of patients were diabetics, 55% had hypertension and 50% presented a history of heart failure. All the patients had a history of acute coronary syndrome [6 (4-26) months before the procedure]. The majority of implanted devices were ICDs (17, 85%) with 5 single chamber, 4 dual chambers and 9 triple chambers ICDs. Subclavian venous approach was utilized in 9 patients. The mean duration of procedure was 60minutes. One per-procedure bleeding was described due to high venous pressure, without post-procedure hematoma. A post-procedure pocket hematoma has been experienced by one patient. The subclavian approach was used for the 2 patients. No blood transfusion was needed for these 2 cases.

CONCLUSION

Ticagrelor treatment at the time of heart rhythm device procedures does not seem to be associated with an increased risk of significant bleeding complications. In our study, 2 patients experienced nonsignificant bleeding complications.

The safety and efficacy of antithrombotic therapy in patients undergoing cardiac rhythm device implantation: a meta-analysis

AIMS

The meta-analysis was to assess the safety and efficacy of periprocedural antithrombotic therapy and to evaluate the risk factors potentially associated with bleeding among patients undergoing cardiac implantable electronic devices implantations.

METHODS AND RESULTS

A systematic literature search of PubMed, EMBASE, and Cochrane Controlled Trials Register was performed. Anticoagulation and antiplatelet therapies were assessed separately. Uninterrupted anticoagulation was associated with significant lower bleeding risk compared with heparin bridging strategy [odds ratio (OR) = 0.31, 95% confidence interval (CI) 0.18-0.53, and P < 0.0001], but there was no significant difference in thromboembolic risk between these two strategies (OR = 0.82, 95% CI 0.32-2.09, and P = 0.65). The haematoma rate was significantly increased in dual antiplatelet therapy group (OR = 6.84, 95% CI 4.16-11.25, and P < 0.00001), but not in single antiplatelet therapy (OR = 1.52, 95% CI 0.93-2.46, and P = 0.09). Clopidogrel increased the risk of haematoma vs. aspirin (OR = 2.91, 95% CI 1.27-6.69, and P = 0.01). Otherwise, a lower risk of haematoma was observed in pacemaker group vs. cardiac resynchronization therapy and/or implantable cardioverter defibrillator group (OR = 0.64, 95% CI 0.50-0.82, and P = 0.0004).

CONCLUSION

This meta-analysis suggested that uninterrupted oral anticoagulation seems to be the better strategy, associated with a lower risk of bleeding complications rather than heparin bridging, and dual antiplatelet therapy carried a significant risk of bleeding whereas single antiplatelet therapy was relatively safe among patients undergoing cardiac implantable electronic devices implantations. Meanwhile, cardiac resynchronization therapy and/or implantable cardioverter defibrillator implantations increase the bleeding.

Reversibility of atrioventricular block according to coronary artery disease: results of a retrospective study

Background and Objectives

The causal relationship of clinically-significant atrioventricular block (AVB) and coronary artery disease (CAD) is uncertain. We investigated whether CAD is related to irreversible AVB that requires treatment with a permanent pacemaker.

Subjects and Methods

We included 188 consecutive patients with new-onset AVB considering pacemaker, who had undergone invasive or noninvasive coronary evaluation. Patients were divided into one of 2 groups: irreversible AVB who underwent implantation of permanent pacemaker {irreversible block (IB) group, n=173} or reversible AVB {reversible block (RB) group, n=15}.

Results

In IB group, significant CAD was observed in 44 patients (25.4%) and there were 2 (1.2%) patients with acute myocardial infarction (AMI). In RB group, 14 patients (93.3%) had CAD (p<0.001) and 13 patients (86.7%) presented with AMI (p<0.001). On the aspect of CAD type and reversibility of AVB, 13/15 (86.7%) patients of AMI, 0/2 (0%) of unstable angina, and 1/41 (2.4%) of stable angina had reversible AVB.

Conclusion

AVB in patients with AMI is usually reversible. Therefore, permanent pacemaker implantation should be delayed in cases of AMI. AVB in patients with CAD other than AMI is usually irreversible.

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.

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.

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.

Morbidity associated with three different antiplatelet regimens in patients undergoing implantation of cardiac rhythm management devices

AIMS

Perioperative management of antiplatelet (AP) therapy in patients undergoing implantation of cardiac rhythm management devices (CRMD) remains an issue of concern that has not been prospectively evaluated in a large series. We sought to describe the morbidity associated with three different AP regimens in this setting.

METHODS AND RESULTS

We conducted a prospective observational study including 849 consecutive patients who were classified in three groups according to the presence of any AP treatment: Group 1 (n= 220): single AP therapy; Group 2 (n= 60): dual AP therapy; and Group 3 (n= 40): oral anticoagulant (OAC) + enoxaparin 'bridging' + AP therapy. Two other groups served as controls: Group 4 (n= 375): no AP or OAC therapy; and Group 5 (n= 154): OAC + enoxaparin 'bridging'. The incidence of pocket haematoma, pocket revisions, hospital stays duration, and unscheduled follow-up visits due to pocket-related complications were compared. Patients on Groups 2, 3 and 5 had significantly higher incidences of pocket haematoma (13.3, 15, and 14.9%, respectively) when compared with Groups 1 and 4 (3.2 and 2.4%, respectively), as well as longer hospital stays and more unscheduled follow-up visits. Of note, only patients on enoxaparin 'bridging' required surgical revision of the pocket. Dual AP therapy (P< 0.001), enoxaparin 'bridging' (P< 0.001) and renal insufficiency (P= 0.02) were independent predictors of pocket haematoma in multivariate analysis.

CONCLUSION

Dual AP therapy and OAC + AP therapy is strongly associated with a significant risk of pocket haematoma, longer hospital stays, and unscheduled follow-up visits. Importantly, surgical revision of the pocket was associated with enoxaparin 'bridging' strategy but was never necessary in patients taking exclusively antiaggregant agents.