Management of Anticoagulation Around Pacemaker and Defibrillator Surgery

Each year, an estimated 1.25 million pacemakers and 410 000 implantable cardioverter-defibrillators are implanted worldwide.1 Clinical trials suggest that ≈25% of pacemaker and 35% of implantable cardioverter-defibrillator patients receive long-term oral anticoagulation (OAC). The periprocedural management of their OAC presents a dilemma. This is particularly true in the subset of patients with moderate to high risk (eg, >5%/y) of arterial thromboembolic events (ATE).The first case is a 76-year-old man with atrial fibrillation, previous embolic stroke, diabetes mellitus, hypertension, and nonischemic cardiomyopathy. His ECG shows atrial fibrillation and left bundle-branch block with a QRS duration of 180 milliseconds, and his left ventricular ejection fraction is 25%. He is on long-term warfarin therapy with a CHADS2 score of 5 and an estimated annual risk of ATE of 12.5%.2 He is recommended for implantation of a cardiac resynchronization defibrillator. How should his warfarin be managed around the device surgery?Physicians responded to concerns about periprocedural ATE by treating moderate- to high-risk patients with heparin bridging, and guidelines recommended this as standard of care.3 However, a number of downsides to heparin bridging around device surgery were observed. First, there is a substantial risk of clinically significant device pocket hematoma related to heparin bridging. The risk of hematoma with bridging is between 17% and 31%.4,5 Importantly, device pocket hematomas …