Access site bleeding complications comparing oral anticoagulation therapy with NOACs and VKAs in patients with atrial fibrillation undergoing cardiac implantable device intervention

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation is frequent in patients undergoing cardiac implantable electronic device (CIED) intervention. Such population require oral anticoagulation therapy, which increases risk of procedure related bleeding. There is a lack on data on procedure-related bleeding outcome with non-vitamin K antagonist anticoagulants (NOACs) vs vitamin K antagonist anticoagulants (VKAs) in patients with AF undergoing CIED intervention.

Study purpose

Aim of the present stud was to evaluate whether NOACs have a safety benefit compared to VKAs in terms of fewer hemorrhagic complications at the site of CIED implant.

Methods

Consecutive AF patients receiving NOACs or VKAs at the time of CIED procedure were included in this observational, retrospective, monocentric investigation. Primary endpoint was the incidence of post-intervention clinically significant pocket hematoma. Multivariate analysis was performed to investigate the association between covariates and the primary endpoint.

Results

A total of 311 patients were enrolled, 146 on NOACs and 165 on VKAs. The incidence of pocket hematoma was 3.4% in the NOAC vs 13.3% in the VKA group (p=0.002) (Figure 1). Primary outcome-free survival at 30-days was 96.6 % in patients on NOACs and 86.0% in those on VKAs (p=0.019) (Figure 2). Multivariate analysis, adjusted by propensity-score calculation of inverse-probability-weighting, showed a significantly lower occurrence of pocket hematoma in patients receiving NOACs vs VKAs (HR 0.35, 95% CI 0.13-0.96, p=0.042). Such NOACs benefit was confirmed vs patients on VKAs without peri-procedural bridging with low-molecular weight heparin (HR 0.34, 95% CI 0.11-0.99, p=0.048). The incidence of pocket infection, surgical pocket evacuation, ischemic events and major bleeding complications at 30 days (secondary endpoints) was similar in the two groups.

Conclusion

Among patients with AF undergoing implantable cardiac defibrillator or pace-maker intervention, the use of NOACs vs VKAs is associated with significant reduction of post-procedural pocket hematoma, regardless of bridging with low molecular-weight heparin in the VKA group.

Comparison of infective complications with two different antibiotic prophylaxis at two-years follow up in patients undergoing cardiac implantable electronic device procedure: a prospective study

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac implantable electronic device (CIED) infective complications are associated with high morbidity and mortality. Selection of proper antibiotic prophylaxis therapy is mandatory, as it can decrease the infective risk.

Purpose of the Study

Aim of the present study was to compare two different antibiotic strategy in term of procedural-related infective complications in a two-years follow-up.

Material and Methods

Patients undergoing CIED procedure (implant, replacement, or revision), with cefuroxime antibiotic prophylaxis during 2009 were consecutively enrolled as study group, with the purpose to have a long follow-up available (10 years). Patients undergoing CIED procedure (implant, replacement, or revision), with cefazolin antibiotic prophylaxis during 2020 were consecutively enrolled as control group. Primary endpoint was the evaluation of infective complications in the first 2 years follow-up (pocket infection, endocarditis and infective complication requiring CIED complete extraction). Multivariate analysis was performed to evaluate association between covariates resulted significantly different between the two study groups and study endpoint. Long-term follow-up incidence of infective complications was evaluated in the cefuroxime group.

Results

340 patients were enrolled in the cefuroxime prophylaxis group and 239 patients in the cefazolin prophylaxis group. There was no significative difference of median age between the two study groups. Patients in the cefazolin prophylaxis group compared to the cefuroxime group showed higher rate of diabetes (33.1% vs 22.1%, p=0.003), dyslipidemia (46.4% vs 36.5%, p=0.02) and higher rate of antiplatelet (45.2% vs 40.6%, p<0.001) and anticoagulation therapy (36.8% vs 31.8%, p<0.001) (Figure 1). ICD and CRT implant was more frequent in patients in the cefazolin group (33.3% vs 25.06%, p=0.05) (Figure 2). There was no significant difference of the primary endpoint in the two study groups: pocket infection (cefazolin group n=4, 1.7%, vs cefuroxime group n=5, 1.5%, p=0.85), endocarditis (cefazolin group n=1, 0.4%, vs cefuroxime group n=1, 0.3%, p=0.8) and infection requiring complete device extraction (cefazolin group n=2, 0.8%, vs cefuroxime group n=2, 0.6%, p=0.95). At multivariate analysis, there was an observed trend in reduction of infective complications in patients undergoing pacemaker (odds ratio 0.23) and CRT (odds ratio 0.82) implant.

At 10 years follow-up, 11 (3.2%) infective procedure-related complications were recorded in the cefuroxime group, 5 pocket infection, 5 pocket infection with erosion and 1 endocarditis.

Conclusion

Cefazolin antibiotic prophylaxis is effective as cefuroxime prophilaxis in reducing CIED procedure-related infections, even if patients in the cefazolin group showed higher prevalence of comorbidities and more complex device procedure (ICD and CRT implant).

Left atrial strain reduction in acute myocarditis and its association with incident atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

The diagnostic and prognostic evaluation of acute myocarditis remains still challenging. Particularly, acute atrial involvement could be underdiagnosed due to its limited evaluation by cardiac magnetic resonance (CMR) and the lack of sensitive basic echocardiographic indices.

Purpose

Our aim was to assess left atrial strain in a cohort of patients with diagnosis of acute myocarditis, and its correlation with incident cardiovascular events at follow up.

Methods

30 patients with acute myocarditis diagnosed by CMR, performed within one week from admission, according to Lake-Louise criteria were retrospectively included. Patients with poor acoustic window or missing data related to hospitalization or follow-up were excluded. Clinical characteristics, laboratory examinations, transthoracic echocardiography data were collected. Speckle tracking analysis was performed offline on the echocardiographic records. Follow up data were obtained via electronical records or phone-calls. Clinical endpoints were the development of all-cause or cardiovascular death, cardiovascular hospitalization (including heart failure, major arrhythmias, acute coronary syndromes), atrial fibrillation or ventricular arrhythmias onset.

Results

The study cohort, composed of 30 patients with acute myocarditis (mean age 38 ±15 years, 33% (n = 10) female), showed raised C-reactive protein and cardiac troponin at admission, beside a mild reduction of left ventricular ejection fraction (Fig.1). Left ventricular strain was preserved in the majority of patients (57%, n = 17) or mildly reduced, while left atrial strain was significantly reduced (Table 1). At CMR, 57% (n = 17) of patients presented myocardial edema and 70% (n = 21) presented late gadolinium enhancement.  Over a mean follow up of 2.3 ± 1.9 years, 5 patients had hospitalizations for cardiovascular reasons, one of whom for heart failure, 3 patients developed atrial fibrillation, 5 patients developed ventricular arrhythmias. Patients with cardiovascular events showed lower left atrial strain than those without events (Fig.2); global atrial reservoir strain reached a statistically significant difference in patients with incident atrial fibrillation vs those without (p = 0.02).

Conclusions

our findings suggest that patients with acute myocarditis may have a subtle atrial involvement which could be detected by speckle tracking echocardiography. Moreover, lower values of left atrial strain may characterize patients at higher risk of incident atrial fibrillation during follow-up. Abstract Figure. Fig.1  Abstract Figure. Fig.2