Evaluation of a new standardized protocol for the perioperative management of chronically anticoagulated patients receiving implantable cardiac arrhythmia devices

Cano, Óscar; Muñoz, Begoña Escutia; Tejada, David; Osca, Joaquín; Sancho‐Tello, María‐José; Olagüe, José; Castro, José Enrique; Salvador, Antonio

doi:10.1016/j.hrthm.2011.10.010

Cited by 30 publications

(30 citation statements)

References 21 publications

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“…Although limited evidence and overlapping CIs hampered our ability to draw conclusions, this group showed higher bleeding rates than either the OAC group or the OAC + UFH group. This finding was consistent with the results of studies evaluating bridging therapy for device implantation in chronically anticoagulated patients receiving implantable cardiac arrhythmia devices . Each of these studies observed higher bleeding rates in the setting of OAC + LMWH bridging than with maintenance of OAC at therapeutic levels during either pacemaker or defibrillator implantation, as demonstrated by a recent meta‐analysis .…”

Section: Discussionsupporting

confidence: 85%

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Early postoperative bridging anticoagulation after mechanical heart valve replacement: a systematic review and meta‐analysis

Passaglia

Barros

Sousa

2015

Journal of Thrombosis and Haemostasis

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To cite this article: Passaglia LG, de Barros GM, de Sousa MR. Early postoperative bridging anticoagulation after mechanical heart valve replacement: a systematic review and meta-analysis. J Thromb Haemost 2015; 13: 1557-67.Summary. Objective: To perform a systematic review and meta-analysis of studies evaluating anticoagulation during the early postoperative period following mechanical heart valve implantation. Methods: Five literature databases were searched to assess the rates of bleeding and thromboembolic events among patients receiving oral anticoagulation (OAC), both with and without bridging anticoagulation therapy with unfractionated heparin (UFH) or subcutaneous low molecular weight heparin (LMWH). The studies' results were pooled via a mixed effects meta-analysis. Heterogeneity (I 2 ) and publication bias were both evaluated. Results: Twenty-three studies including 9534 patients were included. The bleeding rates were 1.8% (95% confidence interval CI 1.0-3.3) in the group receiving OAC, 2.2% (95% CI 0.9-5.3) in the OAC + UFH group, and 5.5% (95% CI 2.9-10.4) in the OAC + LMWH group (P = 0.042). The thromboembolic event rate was 2.1% (95% CI 1.5-2.9) in the group receiving OAC, as compared with 1.1% (95% CI 0.7-1.8) when the bridging therapy groups were combined as follows: OAC + UFH and OAC + LMWH (P = 0.035). Most of the analyses showed moderate heterogeneity and negative test results for publication bias. Conclusions: Bridging therapy following cardiac valve surgery was associated with a lower thromboembolic event rate, although the difference was small, with considerable overlap of the CIs. Direct comparisons are missing. Bridging therapy with UFH appears to be safe; however, this observation has a risk of bias. Early bridging therapy with LMWH appears to be associated with consistently high bleeding rates across multiple analyses. On the basis of the quality of the included studies, more trials are necessary to establish the clinical relevance of bridging therapy and the safety of LMWH.

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Section: Discussionsupporting

confidence: 85%

“…Only three studies used antiplatelet medication in combination with anticoagulants in their protocols: two studies added aspirin , and the other study added aspirin plus dipyridamole . To avoid the introduction of confounding variables, these three studies were excluded.…”

Section: Resultsmentioning

confidence: 99%

Early postoperative bridging anticoagulation after mechanical heart valve replacement: a systematic review and meta‐analysis

Passaglia

Barros

Sousa

2015

Journal of Thrombosis and Haemostasis

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“…Several studies also demonstrated that bridging therapy is associated with a longer hospital stay after the procedure [7,13,14]. This finding is expected, as a patient on bridging therapy with intravenous heparin must be kept in the hospital until their INR reaches the therapeutic range.…”

Section: Risk Of Pocket Hematoma On Bridging Therapy With Heparin or mentioning

confidence: 88%

Perioperative management of anticoagulation in patients on warfarin therapy undergoing surgery for cardiac implantable electronic devices

Zhu

Ahmed

2013

Journal of Arrhythmia

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Many patients on chronic warfarin therapy are undergoing surgery for permanent pacemakers and implantable defibrillators, collectively known as cardiac implantable electronic device (CIED). The perioperative management of anticoagulation in these patients is a challenging clinical situation that requires balance between the risk of acute thrombosis and perioperative hemorrhage. This issue however, is inadequately addressed in the guidelines published by professional organizations. Increasing evidence suggests that temporarily interrupting anticoagulation is associated with a small but real thromboembolic risk, whereas cessation of warfarin with heparin bridging anticoagulation frequently leads to a higher incidence of pocket hematoma. Continuing warfarin with a therapeutic international normalized ratio appears to be a safe and cost‐effective approach for CIED surgery in most patients with moderate to high thromboembolic risk. An algorithm is proposed for the practical management of anticoagulation and antiplatelet therapy in these patients during the perioperative period.

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“…The recent studies allowed Ghanbari et al to identify eight studies enrolling 2,321 patients for a meta‐analysis comparing uninterrupted warfarin compared with heparin‐based bridging therapy during implantation of cardiac rhythm devices . There were three randomized trials .…”

Section: Uninterrupted Warfarin Therapymentioning

confidence: 99%

Uninterrupted Warfarin Therapy for the Implantation of Cardiac Rhythm Devices

Barold

Giudici

Herweg

2013

Pacing Clinical Electrophis

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Evaluation of a new standardized protocol for the perioperative management of chronically anticoagulated patients receiving implantable cardiac arrhythmia devices

Cited by 30 publications

References 21 publications

Early postoperative bridging anticoagulation after mechanical heart valve replacement: a systematic review and meta‐analysis

Early postoperative bridging anticoagulation after mechanical heart valve replacement: a systematic review and meta‐analysis

Perioperative management of anticoagulation in patients on warfarin therapy undergoing surgery for cardiac implantable electronic devices

Uninterrupted Warfarin Therapy for the Implantation of Cardiac Rhythm Devices

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