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Meta-Analysis
. 2025 Jun;68(4):845-856.
doi: 10.1007/s10840-024-01947-z. Epub 2024 Nov 15.

Perioperative direct oral anticoagulant management during cardiac implantable electronic device surgery: an updated systematic review and meta-analysis

Chidubem Ezenna  1 , Vinicius Pereira  2 , Mohammed Abozenah  3 , Ancy Jenil Franco  4 , Oghenetejiri Gbegbaje  5 , Ayesha Zaidi  6 , Mrinal Murali Krishna  7 , Meghna Joseph  7 , Prasana Ramesh  6 , Fadi Chalhoub  3
Affiliations
Meta-Analysis

Perioperative direct oral anticoagulant management during cardiac implantable electronic device surgery: an updated systematic review and meta-analysis

Chidubem Ezenna et al. J Interv Card Electrophysiol. 2025 Jun.

Abstract

Background: Patients undergoing cardiovascular implantable electronic device (CIED) implantation are often on direct oral anticoagulation (DOAC). However, the evidence on whether to continue or temporarily discontinue DOAC therapy during the perioperative period in these patients is unclear.

Methods: We conducted a comprehensive literature review using PubMed, Embase, and Cochrane databases through July 2024. We included studies comparing uninterrupted versus interrupted perioperative DOAC therapy in patients undergoing CIED procedure- primary implants, pulse generator replacement, and device upgrades. Primary outcomes were clinically significant device-pocket hematoma and thromboembolic events. Secondary outcomes included any device-pocket hematoma, all-cause mortality, major bleeding, and any bleeding.

Results: A total of 1,607 patients from 8 studies were included. The mean age was 73.2 years, with atrial fibrillation as the indication for DOAC therapy in most patients. The mean CHA2DS2-VASc was 3.4. Among the included studies, 2 were randomized control trials (RCTs), while the others were observational cohort studies, including one that was propensity score matched. Our meta-analysis found both strategies to be similar in terms of clinically significant pocket hematoma (RR 1.70; 95%CI 0.84-3.45; p = 0.14; I2 = 0%), thromboembolic complications (RR 0.35; 95%CI 0.04-3.32; p = 0.36; I2 = 19%), any pocket hematoma, all-cause mortality and any bleeding with a higher risk of major bleeding with uninterrupted anticoagulation.

Conclusion: This meta-analysis shows that uninterrupted DOAC therapy is comparable to interrupted therapy for CIED procedures, with a potential increase in major bleeding risk but low overall complication rates. Further research is needed to confirm the best approach of periprocedural anticoagulation in these patients.

Keywords: Bleeding; DOAC; Defibrillator; Direct oral anticoagulants; Hematoma; Pacemaker.

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Conflict of interest statement

Declarations. Ethics approval: Not applicable. Consent to participate: Not applicable. Consent for publication: Not applicable. Conflicts of interest: None. Competing interests: The authors have no relevant financial or non-financial interests to disclose. Disclosure: All authors have nothing to disclose.

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References

    1. Mond HG, Proclemer A. The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: calendar year 2009 – a World Society of Arrhythmia’s project. Pacing Clin Electrophysiol. 2011;34:1013–27. - PubMed
    1. McCallum CJ, Raja DC, Pathak RK. Atrial fibrillation: an update on management. Aust Prescr. 2019;42(6):186–91. https://doi.org/10.18773/austprescr.2019.067 . - DOI - PubMed - PMC
    1. Dunn AS, Turpie AGG. Perioperative Management of Patients Receiving Oral Anticoagulants: A Systematic Review. Arch Intern Med. 2003;163(8):901–8. https://doi.org/10.1001/archinte.163.8.901 . - DOI - PubMed
    1. Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084–93. - PubMed
    1. Carbone A, Bottino R, D’Andrea A, Russo V. Direct Oral Anticoagulants for Stroke Prevention in Special Populations: Beyond the Clinical Trials. Biomedicines. 2023;11(1):131. https://doi.org/10.3390/biomedicines11010131 . - DOI - PubMed - PMC

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