Increased risk of hematoma with uninterrupted warfarin in patients undergoing implantation of subcutaneous implantable cardioverter defibrillator

Abstract

Background The perioperative management of anticoagulation with the use of subcutaneous implantable cardioverter‐defibrillator (S‐ICD) implantation is still evolving. Objective The purpose of this study was to assess whether it is safe to perform S‐ICD implantation with uninterrupted warfarin. Methods This is a multi‐center retrospective review of patients undergoing S‐ICD implantation between October 1, 2012 and June 30, 2017. Forty‐eight patients underwent successful S‐ICD implantation during the study period. The most common indication for implantation was primary prevention of sudden cardiac death. In 23 (47.9%) patients, warfarin was continued without any interruption. In 25 (52.1%) patients, warfarin was interrupted prior to implantation. The incidence of clinically significant lateral pocket hematoma was compared in the two groups. Results The mean international normalized ratio was 2.0 ± 0.4 in the uninterrupted group and 1.4 ± 0.4 for the interrupted group. A total of seven patients developed a hematoma at the lateral pocket. No patient developed a hematoma at the parasternal pockets. Six patients in the uninterrupted group (26.1%) and one patient in the interrupted group (0.04%) developed a significant lateral pocket hematoma (P = .04). The concomitant use of dual antiplatelet therapy did not increase the risk of hematoma. There was no significant difference between HASBLED and CHA2DS2VASc scores between the groups. None of the patients with a hematoma developed infection or required hematoma evacuation. Conclusions The uninterrupted use of warfarin in the perioperative period of S‐ICD implantation is associated with an increased risk of lateral pocket hematoma.

Ultrasound-guided intermuscular pocket creation for a subcutaneous implantable cardioverter-defibrillator

“…Further, several papers have reported that an uninterrupted use of anticoagulation and antiplatelet is associated with an increased risk of hematoma. 8 , 9 , 10 Further, we believe that our ultrasound-guided methods can contribute to reducing the bleeding risk in such patients.…”

Subcutaneous implantable cardioverter defibrillator: Can it overtake its transvenous counterpart

“…implanted S‐ICD into 48 patients with 47.9% having uninterrupted warfarin therapy and 52.1% with interrupted warfarin therapy. They found an increased risk of hematoma formation in the uninterrupted group (26.1%) as oppose to the interrupted group (0.02%) 42 . More research needs to be performed on the effects of uninterrupted DOAC therapy in hematoma formation in S‐ICD insertion.…”

Process mapping strategies to prevent subcutaneous implantable cardioverter‐defibrillator infections

“…For patients on oral anticoagulant (OAC) medications, an important step to reduce the risk of infection is to establish a perioperative plan for OAC use. The use of OACs increases the risk of surgical bleeding and hematoma formation, 12,13 which is strongly associated with an increased risk of TV device‐related infections 14 . Because perioperative interruption of OACs may lead to an unacceptable risk of clotting sequelae, heparin bridging has been used as an alternative to OAC continuation during surgery, but this too is associated with an increased risk of hematoma formation 15,16 .…”