Anticoagulation Bridging Around Device Surgery: Compliance with Guidelines

Abstract

Our study identified significant underutilization of bridging, particularly in the postoperative period, in patients at "moderate/high risk" of thromboembolism. Conversely, bridging was overused in "low risk" patients and associated with bleeding complications. Physicians should be urged to follow current expert guidelines in regard to bridging anticoagulation for cardiac rhythm device surgery. (PACE 2012;35:1480-1486).

Uninterrupted Warfarin Therapy for the Implantation of Cardiac Rhythm Devices

“…Uninterrupted warfarin therapy seems be safer than bridging therapy in terms of bleeding complications and perhaps in preventing thromboembolic complications though the latter remains to be further defined. Uninterrupted warfarin therapy would provide a more uniform approach to anticoagulation therapy in the perioperative period than the present marked variability in the application of the current guidelines with and without recommendations for bridging . Uninterrupted warfarin therapy with a therapeutic INR in patients with moderate to high thromboembolic risk avoids heparin therapy and it appears safe, simple, and cost‐effective.…”

“…Uninterrupted warfarin therapy with a therapeutic INR in patients with moderate to high thromboembolic risk avoids heparin therapy and it appears safe, simple, and cost‐effective. On this basis we suggest that the guidelines be modified with a statement to reflect the two strategies (bridging vs uninterrupted warfarin) are equally applicable for implantation of cardiac rhythm devices at this time without waiting for the results of several randomized trials that will address the remaining uncertainty of periprocedural bridging anticoagulation . With uninterrupted warfarin therapy, on the day of surgery the INR should be <3.0 and ideally between 2 and 2.5.…”

“…Uninterrupted warfarin therapy would provide a more uniform approach to anticoagulation therapy in the perioperative period than the present marked variability in the application of the current guidelines with and without recommendations for bridging. 38,39 Uninterrupted warfarin therapy with a therapeutic INR in patients with moderate to high thromboembolic risk avoids heparin therapy and it appears safe, simple, and cost-effective. On this basis we suggest that the guidelines be modified with a statement to reflect the two strategies (bridging vs uninterrupted warfarin) are equally applicable for implantation of cardiac rhythm devices at this time without waiting for the results of several randomized trials that will address the remaining uncertainty of periprocedural bridging anticoagulation.…”

“…On this basis we suggest that the guidelines be modified with a statement to reflect the two strategies (bridging vs uninterrupted warfarin) are equally applicable for implantation of cardiac rhythm devices at this time without waiting for the results of several randomized trials that will address the remaining uncertainty of periprocedural bridging anticoagulation. 35,39,40 With uninterrupted warfarin therapy, on the day of surgery the INR should be <3.0 and ideally between 2 and 2.5. This approach applies to primary implantations and should not be extrapolated to patients undergoing other types of device procedures, though early experience suggests that the same approach may be applicable to the implantation of cardiac resynchronization devices.…”

Systematic Implantation of Pacemaker/ICDs under Active Oral Anticoagulation Irrespective of Patient's Individual Preoperative Thromboembolic Risk

“…Recently, different studies have shown that implantation of CRMDs under active OAC in high TE risk patients is not only safe, but also associated with a lower incidence of pocket bleeding complications when compared with the classic heparin bridging strategy . In any case, both strategies rely on an adequate classification of patients according to their TE risk and this process may be time consuming and subjected to a great variability depending on the attending physician criteria …”