Peri-device implantation anticoagulation management: Evidence and clinical implications

Abstract

Implantation rates of cardiovascular implantable electronic devices (CIED) have increased over the past decade. A significant number of patients undergoing CIED implantation are treated with oral anticoagulants (OAC). The perioperative management of anticoagulant therapy is often challenging. Selecting a management strategy for anticoagulation therapy depends on a balance between the risk of hemorrhagic complications in the perioperative period and the risk of thrombotic complications. For patients with a low thrombotic risk, short-term interruption of OAC is recommended. For patients with moderate and higher risk of thrombotic complications, interruption of OAC could be unsafe, and bridging anticoagulation with parenteral agents is suggested. This approach, unfortunately, has serious limitations. For this reason, some physicians perform CIED implantation with OAC. However, the relative effectiveness and safety of both approaches remains to be determined by further randomized controlled trials. In this chapter, we provide the rationale for deciding on appropriate antithrombotic management strategy in the perioperative period, discuss advantages and disadvantages of each approach, underline existing evidence, and compare current guidelines for perioperative anticoagulant management. We also review the new oral anticoagulants such as direct thrombin inhibitors and factor Xa inhibitors and discuss implications regarding anticoagulation management during CIED implantation.