Oral Anticoagulants, With Cautions, Can Continue During CIED Lead Extractions

June 20, 2017

VIENNA, AUSTRIA — With the right cautions, there may be no need to discontinue oral anticoagulation (OAC) prior to procedures for extracting unwanted cardiac implantable electronic device (CIED) leads, suggests a retrospective series from a high-volume lead-extraction center[1].

That experience suggests that withdrawing OAC and then bridging the patients on heparin during the procedure did not meaningfully cut the risk of bleeding complications and may actually make such bleeding more likely, it was reported here at the European Heart Rhythm Association (EHRA) EUROPACE-CARDIOSTIM 2017 sessions.

Dr Ulrika Birgersdotter-Green

"In the few patients who did get bridging, there was a trend toward an increase in bleeding complications," Dr Ulrika Birgersdotter-Green (University of California, San Diego) told theheart.org|Medscape Cardiology

The numbers are small and the findings retrospective and in need of confirmation in prospective trials, but they at least suggest that heparin bridging during lead extractions "is unnecessary whether the patient is on warfarin or one of the [new oral anticoagulants] NOACs," said Birgersdotter-Green in an interview after presenting the study.

Caveats, she said, include careful anticoagulation management for the patient remaining on the OAC, at experienced centers with fast access to a surgeon should there be a serious complication during the procedure with anticoagulants on board.

"If you are at a high-volume center with surgical backup, with the skill set and the expertise, then it can be done."

Lead extractions are increasingly common as more patients with CIEDs get replacement or upgraded systems, and up to a third or so need chronic OAC; yet there are no guidelines for managing anticoagulation during the extraction procedure.

Because lead extractions are generally performed percutaneously but can quickly turn into a surgical procedure if there are severe complications, concerns were that a patient who continued on oral anticoagulation could bleed to death.

Dr Jean-Claude Deharo

"There's no standard practice," said Prof Jean-Claude Deharo (Hôpital de la Timone, Marseille, France) in an interview. "I think we all follow the same rules as for elective surgery. So we stop anticoagulation in the majority of patients."

Heparin bridging—that is, using a heparin drip to maintain anticoagulation—was intuitively appealing because it can be stopped fairly quickly, with resumption of OAC after the procedure, Deharo observed. But "the very-severe-complication rate was so low in their experience, they did not have to go to surgery in a sufficient number of patients to see a difference between stopping and not stopping anticoagulation."

The study says there is no advantage to heparin bridging, he said, and that it is generally fine to keep the patient on OAC, whether vitamin-K antagonists (VKA) like warfarin, or the NOACs, which are factor Xa inhibitors or a direct thrombin inhibitor. That's on the condition that there is fast surgical backup, "which is best practice" anyway.

Birgersdotter-Green and her colleagues looked at 6 years of the procedure at their center, performed until last year in 400 patients, who accounted for a total of 739 extracted leads.

Of that group, major or minor bleeding complications developed in 16 patients (4% of the cohort): nine who had been on anticoagulation during the procedure, and seven who had the procedure off anticoagulation, not a significant difference.

If they had been on warfarin at referral, usually they maintained warfarin throughout the procedure and may have been bridged too; if they had been on a NOAC, they discontinued it 1 to 2 days prior to the procedure per practice at the time and then were bridged.

Of the nine bleeding complications on anticoagulation, seven were major and included two who had been on a NOAC and bridged, four on warfarin who were bridged, and one who had continuous warfarin without bridging; two were minor and included one on warfarin who was bridged and one on warfarin without bridging.

Of the seven bleeding complications during extractions off all anticoagulation, three were major and four were minor.

There were no significant associations between major and minor bleeding and any form of anticoagulation management, whether continuous warfarin, NOAC use, or heparin bridging (P>0.05).

In an analysis adjusted for clinical variables, Birgersdotter-Green said, there was a nonsignificant trend (P=0.06) toward more major or minor bleeding complications in patients who received heparin bridging, regardless of their chronic OAC regimen. Among those who were bridged, implant duration was the only observed significant predictor of major bleeding (P=0.04).

Deharo said the UCSD group is "promoting a pragmatic approach," one in which patients continue their OAC, and there is no bridging to complicate the procedure. "The number of complications [without bridging] is so low, they could not show any difference."

Neither Deharo nor Birgersdotter-Green had relevant financial relationships.

Follow Steve Stiles on Twitter: @SteveStiles2. For more from theheart.org, follow us on Twitter and Facebook .

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