Anticoagulation and Antiplatelet Therapy in Implantation of Electrophysiological Devices

Panagiotis Korantzopoulos; Konstantinos P. Letsas; Tong Liu; Nikolaos Fragakis; Michael Efremidis; John A. Goudevenos

Disclosures

Europace. 2011;13(12):1669-1680. 

In This Article

Abstract and Introduction

Abstract

The growing implantations of electrophysiological devices in the context of increasing rates of chronic antithrombotic therapy in cardiovascular disease patients underscore the importance of an effective periprocedural prophylactic strategy for prevention of bleeding complications. In this review, we provide a concise overview of the data regarding anticoagulation and antiplatelet therapy in arrhythmia device surgery. Also, we critically discuss risk factors and procedural parameters that are potentially associated with haemorrhagic untoward events in this setting. Of note, current evidence suggests that heparin bridging therapy in patients on chronic anticoagulation and dual-antiplatelet therapy are associated with increased risk of pocket haematoma formation. Continuation of oral anticoagulation and short-term interruption of clopidogrel with aspirin maintenance in eligible patients, respectively, represent promising strategies with an acceptable safety profile. Besides the perioperative management of antithrombotic therapy, some extra supportive measures may also reduce the incidence of haematomas. High-risk cases should be better treated by experienced operators in high-volume centres. More randomized studies are needed to elucidate the exact role of particular antithrombotic therapy protocols. Finally, the recently accumulated data on this subject should be incorporated into the professional guidelines regarding arrhythmia device therapy.

Introduction

More than 50 years after the first permanent pacemaker (PPM) implantation, we witness the continuous development and growing clinical application of implantable devices in a wide range of heart rhythm disorders.[1–3] Apart from the conventional use of PPMs for the management of bradycardia, more sophisticated devices are increasingly used for cardiac resynchronization therapy (CRT) in heart failure while the implantable cardioverter–defibrillator (ICD) has become established as the most effective therapy against malignant arrhythmias and sudden cardiac death.[2,3]

Data on temporal trends of implantation rates are sparse, but there have clearly been considerable increases over past decades.[4,5] Potential factors that possibly contribute to the increase in implantation rates of electrophysiological devices (EPDs) include an ageing population, advances in device technology, and the growing number of evidence-based indications.[4,5] Also, there is an increase in other related operations such as upgrade procedures, device/lead revisions, and lead extractions. The complexity of the modern advanced devices requiring longer and more sophisticated procedures for implantation as well as the comorbidities and medications of the patients may increase the risk of complications.

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