Anticoagulant therapy during cardiovascular implantable electronic device procedures

Abstract

Aim: The objective of the study is to systematically evaluate the safety and efficacy of peri-procedural utilization of anticoagulation therapy during cardiovascular implantable electronic device procedures.

Material and methods: The review materials were based on comprehensive retrieval of randomized controlled trials and observational studies published until April 2023. Studies which compared different management strategies of long-term anticoagulation therapy during peri-procedural cardiac rhythm device implantation and compared the complications of bleeding and/or thromboembolic events were selected and reviewed.

Results: Studies analysing non-vitamin K oral anticoagulants interruption versus continuation during peri-procedural implantable cardiac device surgery found no statistically significant difference in bleeding or thromboembolic complications between these strategies. Studies comparing non-vitamin K oral anticoagulants with vitamin K antagonists also showed no statistically significant difference. One study comparing uninterrupted warfarin with interrupted warfarin with heparin bridging reported a reduced incidence of clinically significant device pocket haematoma in patients with continued warfarin treatment (relative risk = 0.19; 95% confidence interval: 0.10 to 0.36; p < 0.001). A sub-analysis of one study comparing dabigatran versus warfarin with heparin bridging and without bridging reported a lower risk of pocket haematoma with dabigatran when compared to warfarin with heparin bridging (risk difference: -8.62%, 95% confidence interval: -24.15 to -0.51%; p = 0.034). Both bleeding and thromboembolic complications were rare.

Conclusions: The traditional method of vitamin K antagonists interruption with heparin bridging is less safe than continuing vitamin K antagonists at therapeutic levels. Both continuation and interruption strategies of non-vitamin K anticoagulants during cardiac device surgery seem to be safe and appropriate.

Keywords: anticoagulation; cardiac resynchronization therapy; device pocket haematoma; implantable cardioverter-defibrillator; pacemaker.

Figure 1

Flow chart of article selection process. Adapted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework [55]