Non-vitamin K oral anticoagulants at the time of cardiac rhythm device surgery: A systematic review and meta-analysis

Abstract

Introduction: Between 14% and 35% of the patients requiring cardiac implantable electronic device (CIED) surgery are on chronic oral anticoagulant therapy. Novel oral anticoagulants (NOACs) have emerged as a valid and more practical alternative to warfarin, and their widespread use has rapidly increased worldwide. We aimed to systematically assess the available evidence regarding the safety and efficacy of NOACs in patients undergoing CIEDs surgery.Methods: We performed a systematic literature search of PubMed, EMBASE and Cochrane Controlled Register of Trials (from inception to March 2019). Eligible randomised controlled trials and cohort studies were included. The primary outcome measures were clinically significant device-pocket haematoma and thromboembolic events.Results: A total of 12 studies were included, equating to a population of 2120 patients. All but 2 studies reported the incidence of clinically significant device-pocket haematoma, which occurred in 17 out of 1687 patients (1%;CI95%0.6-1.6). Any device-pocket haematoma occurred in 68 out of 2120 individuals (3.2%;CI95%2.5-4.0). A total of 8 thromboembolic events (0.4%;CI95%0.2-0.8) were reported during the follow-up. From a meta-analysis of 3 studies (equating to 773 subjects) allowing for a comparison of continued versus interrupted NOAC, we found no significant difference between the 2 strategies in terms of clinically significant pocket haematoma (1.14;CI95%0.43-3.06, p=0.79), thromboembolic complications (1.03;CI95%0.06-16.37, p=0.98), and any pocket haematoma (1.19;CI95%0.65-2.20, p=0.57). Conclusion:Use of NOACs at the time of CIEDs surgery is safe, and either strategy of periprocedure continuation or interruption appears to be reasonable.

Non–vitamin K oral anticoagulants in hypertrophic cardiomyopathy patients undergoing catheter ablation of atrial fibrillation

“…[2][3][4] Non-vitamin K anticoagulants (NOACs) have emerged as a valid and more practical alternative to vitamin K antagonists (VKAs). 5,6 Even though data supporting the use of NOACs in patients with HCM and AF are sparse, recent observational studies suggest that NOACs might be safely used in this population. 7 Catheter ablation is an established treatment for AF and is also used in subjects with HCM.…”

Pocket hematoma after pacemaker or defibrillator surgery: Direct oral anticoagulants versus vitamin K antagonists

“…[3] Several single-center studies have demonstrated a similar low risk of clinically significant pocket hematoma when using continued DOAC, [24] , [25] however, a recent meta -analysis demonstrated a numerically higher incidence of bleeding complications in patients who continued DOAC. [14] Furthermore, many centers still prefer a interrupted DOAC regimen. [15] …”

“…[3] However, a meta -analysis in 2020 demonstrated a numerically higher incidence of bleeding complications in patients who continued DOAC. [14] Furthermore, a large European survey demonstrated that in the majority of patients (89%) an interrupted DOAC strategy was used. [15] The ESC guidelines and a EHRA expert consensus statement did not suggest a preference for either continued or interrupted DOAC during CIED surgery.…”

Perioperative coagulation activation after permanent pacemaker placement

“…Bradyarrhythmias are typically treated with permanent PM. The elimination of bradyarrhythmia by PM implantation improves the patient's quality of life and prognosis, but it can also result in a number of sequalae[ 1 , 3 , 4 ]. It is still unclear how PM implantation affects the hemostasis system's parameters and how those parameters relate to different problems and other consequences.…”