Peri-procedural Anticoagulation and the Incidence of Haematoma Formation after Permanent Pacemaker Implantation in the Elderly

Background: Haematoma formation is a recognised complication after permanent pacemaker (PPM) implantation. The contribution of pen-procedural anticoagulation to the risk of haematoma formation is unclear. Method: The records of 518 consecutive patients, mean age 76.9 +/- 9.8 years, receiving their first PPM (2004-2007) in a single tertiary referral centre were reviewed. Follow-up was complete for 506 patients (97.7%) up to six weeks. Haematomas were diagnosed clinically, and further subdivided according to the need for evacuation. Results: There were 27 instances of haematoma formation in 25 patients (4.9%) with 19 requiring drainage or evacuation. Twenty-one of the 25 patients who developed a haematoma had stopped warfarin and received bridging therapeutic anticoagulation pre- and post-PPM. The incidence of haematoma was significantly greater in those receiving pen-operative therapeutic anticoagulation (26.9% vs 0.9%, p < 0.001), but was unaffected by the use of anti-platelet therapy. Most haematomas developed in patients whose heparin was recommenced within 24 hours of implantation. The development of haematoma post-PPM increased median hospital stay significantly (p < 0.001). The main indication for anticoagulation in these patients was atrial fibrillation (79.5%) and most of these patients had a low to intermediate risk of pen-procedural thromboembolic events. Conclusion: Pen-operative therapeutic anticoagulation is associated with more than 25-fold increase in haematoma formation post-pacemaker implantation. The risk-benefit ratio of therapeutic anticoagulation should be carefully considered, particularly in patients with a low risk of thromboembolic events. (Heart, Lung and Circulation 2010;19:706-712) (C) 2010 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.