Perioperative anticoagulation in patients having implantation of a cardiac pacemaker or defibrillator: a systematic review and practical management guide

Abstract

To cite this article: Jamula E, Douketis JD, Schulman S. Perioperative anticoagulation in patients having implantation of a cardiac pacemaker or defibrillator: a systematic review and practical management guide. J Thromb Haemost 2008; 6: 1615-21.Summary. Background: The perioperative management of anticoagulation in patients who are having implantation of a pacemaker or implantable cardioverter defibrillator (ICD) is a common clinical problem in which best clinical practise is not established. Methods: We performed a systematic review of the literature to assess the safety (pocket hematoma risk) and efficacy (thromboembolism risk) of different management strategies. We included studies involving patients who were having pacemaker or ICD implantation whenever a portion of these patients were receiving a coumarin and also assessed pocket hematoma or thromboembolism. Results: We identified eight studies that assessed two strategies used for perioperative anticoagulation management: interruption of a coumarin and use of bridging anticoagulation with a short-acting heparin; and perioperative continuation of a coumarin. A strategy involving bridging anticoagulation with therapeutic-dose heparin was associated with an incidence of pocket hematoma of 12-20%. A strategy involving perioperative continuation of a coumarin was associated with an incidence of pocket bleeding of 1.9-6.6%. The incidence of thromboembolic events was 0-1%, irrespective of the perioperative anticoagulation strategy used. Conclusion: The perioperative anticoagulation management of patients who require pacemaker or ICD implantation is not established but a strategy involving postoperative bridging with intravenous heparin confers a high risk for bleeding whereas perioperative continuation of a coumarin appears to confer a lower risk for bleeding.

Thromboembolic Events During the Perioperative Period in Patients Undergoing Permanent Pacemaker Implantation

“…17 However, other data indicate that an elevated risk for pocket hematoma exists in patients who undergo pacemaker implantation without interruption of oral anticoagulation. 18 It also has been demonstrated that use of heparin initiated 6 or 24 hours after implantation or use of high doses of heparin may significantly increase the risk of bleeding. 10,18 In a meta-analysis study, 18 the perioperative management of patients with a high risk of TE event was not established.…”

“…18 It also has been demonstrated that use of heparin initiated 6 or 24 hours after implantation or use of high doses of heparin may significantly increase the risk of bleeding. 10,18 In a meta-analysis study, 18 the perioperative management of patients with a high risk of TE event was not established. Managing patients with a high risk for TE events continues to be difficult and requires further study to establish a recommendation.…”

Complications in recipients of cardioverter-defibrillator or cardiac resynchronization therapy: Insights from Silesian Center Defibrillator registry

“…In most cases, antiplatelet therapy can be safely discontinued for a period of 5-7 days, especially when recommended for primary prevention [16,17]. Additionally, the use of heparin (UFH or LMWH) as bridging therapy during interruption of OAC increased the risk of bleeding and some authors suggest performing implantation procedures without OAC therapy cessation [18,19]. There are no data available regarding periprocedural treatment of patients treated previously with new OAC.…”

Heparin Bridging vs. Uninterrupted Oral Anticoagulation in Patients With Atrial Fibrillation Undergoing Coronary Artery Stenting

“…10-13 BT offered no advantages in any of these studies and might even have increased bleeding events. 12 Furthermore, heparin bridging prolongs hospitalization, 14,15 and may also contribute to the observations that patients with acute coronary syndromes while on long-term OAC are significantly less likely to undergo coronary angiography and PCI, and waiting times for these procedures are longer in the OAC-treated patients than in those not on OAC. 14 In AF patients on OAC, effective anticoagulation is necessary during PCI not only to avoid thromboembolic complications, but also to avoid thrombotic complications of the intervention.…”