Evaluation of a new standardized protocol for the perioperative management of chronically anticoagulated patients receiving implantable cardiac arrhythmia devices

BACKGROUND Perioperative management of oral anticoagulation (OAC) in patients receiving pacemakers or implantable cardioverter-defibrillators remains an issue of concern. OBJECTIVE We sought to evaluate the safety and the effect on the hospital length of stay of a new standardized protocol for perioperative management of OAC in this setting. METHODS The new standardized protocol classified patients according to a renewed evaluation of their thromboembolic (TE) risk. Briefly, patients were considered at moderate-to-high TE risk if they had a mechanical valvular prostheses irrespective of type and location or atrial fibrillation associated with a CHADS2score of >= 2, mitral stenosis or previous stroke, and underwent device implantation without stopping OAC (OAC continued, n = 129). Complete interruption of OAC before surgery was performed in low-TE-risk patients (OAC interrupted, n = 82). A retrospective cohort of patients managed with a classic heparin-bridging strategy served as a control group, with 62 patients considered at moderate-to-high TE risk according to previous guidelines (receiving pre- and postoperative low-molecular-weight heparin) and 146 considered at low TE risk (receiving only low doses of postoperative low-molecular-weight heparin). RESULTS TE events were comparable between the 2 strategies. Patients entering the new standardized protocol had significantly lower rates of pocket hematoma (2.3% for OAC continued vs 17.7% for moderate-to-high TE risk bridging controls, P = .0001, and 0% for OAC interrupted vs 13% for low-TE-risk bridging controls, P < .0001) and shorter hospital stays. A mean of 3.34 hospitalization days per patient were saved with the new standardized protocol, with an estimated cost savings of (sic)850.83 per patient. CONCLUSIONS Implantation of the new standardized protocol resulted in a significant reduction in bleeding complications and hospital stays, with adequate protection against TE events and significant cost savings.