Management of Direct Oral Anticoagulants Surrounding Placement or Revision of Cardiac Implantable Electronic Devices

Abstract

Background:

Pocket hematoma is a rare complication in patients on anticoagulation after placement of cardiac implantable electronic devices (CIEDs). Current guidance for periprocedural management of direct oral anticoagulants (DOACs) varies.

Objective:

The objective was to report the time before and after procedure that a DOAC was interrupted, compare with guideline best practice, and report the incidence of device-related pocket hematoma.

Methods:

This was a single-center retrospective chart review of patients admitted for CIED insertion or revision from January 2018 to September 2021. Patients were included if on apixaban, edoxaban, rivaroxaban, or dabigatran prior to a CIED procedure. Patients excluded if the time of last DOAC dose was not documented in the inpatient health record or if there was no record of patient advice on stopping time as an outpatient prior to procedure. Major endpoints included time from last dose of DOAC prior to and reinitiation after procedure. Minor endpoints included incidence of device-related pocket hematoma and major bleeding events defined by the International Society of Thrombosis and Haemostasis.

Results:

A total of 214 patients were included and analyzed. The median time a DOAC was held prior to procedure was 39.9 hours [24.4, 61.6] with 68.2% (146 patients) restarting at least 36 hours or more postprocedure. The incidence of device-related pocket hematoma was 8.9% (19 patients) and major bleeding occurred in 1.9% (4 patients).

Conclusions and Relevance:

Time from last dose of DOAC prior to and reinitiation after procedure varies, and impaired renal function did not appear to be a factor in longer hold durations. The results of this study demonstrate that few patients continue DOAC therapy uninterrupted before CIED procedures. This study found that DOAC periprocedural management varies despite institutional and management guidelines from clinical trials and might not be driven by patient’s renal function and clearance of DOAC.