Comparison of Cardiac Rhythm Device Surgery with Interrupted and Continued Oral Anticoagulation in Patients with Implanted Ventricular Assist Device

Objectives: The aim of the study was to evaluate bleeding complications associated with cardiac rhythm device surgery in patients with implanted ventricular assist devices (VAD). Patients with continued oral anticoagulation and patients with heparin bridging during the surgical interval were compared.

Methods: A total of 59 consecutive patients were analyzed. After institutional retrospective analysis of 37 patients (2009–2014) with heparin bridging prior to surgery, we changed with respect to the findings of this group our anticoagulation protocol and performed further interventions under continuous oral anticoagulation (warfarin) from that point onward (2015–2018).

Results: All procedures were performed successfully with no procedure-related deaths. Bleeding complications attributable to the surgical intervention occurred in one patient of the continued oral anticoagulation group (4.5%, p < 0.05) and in eight patients of the heparin bridging group (21.6%, p < 0.05). The mean interval between intervention and bleeding or hematoma was 5.7 ± 4.9 days. There was no difference in baseline characteristics between the groups. The mean INR in the heparin and oral anticoagulation group was 1.5 ± 0.3 and 2.2 ± 0.3, respectively (p < 0.001). In addition, there was a significant difference in platelet count (209 × 10³ ± 104 × 10³ in the heparin group vs. 154 × 10³ ± 91 × 10³ in the warfarin group, p < 0.05). There was no difference in additional medication with aspirin or clopidogrel. A subgroup analysis to investigate the causes of bleeding showed a tendency to higher risk of bleeding for subpectoral implantation compared with a subcutaneous approach without reaching statistical significance. No thromboembolic events or VAD-related thrombosis in either group were observed.

Conclusion: We could show that without heparin bridging, the frequency of bleeding complications is significantly lower without an increase in thromboembolic events. The delayed incidence of bleeding suggests that reinitiation of oral anticoagulation in supplement with intravenous heparin represents a vulnerable period for bleeding and the development of hematoma. Performing cardiac rhythm device surgery with continued oral anticoagulation is safe and reduces bleeding complications significantly in patients with implanted VAD. Based on the results of this study, the surgical protocol in our hospital was adjusted accordingly.

No conflict of interest has been declared by the author(s).