Summary and general discussion 171 and this also requires meticulous attention to risk factors, including renal failure, congestive heart failure, low operator experience, concomitant antiplatelet therapy, device replacement, lead revision, and heparin bridging (27, 28). Periprocedural oral anticoagulation is associated with a higher likelihood for pocket hematoma (29). Discontinuing DOACs 24–48 hours before surgery depending on renal function status, or targeting an international normalised ratio of 2.0 to 2.5, and avoiding heparin bridging were important changes in anticoagulation regimen over the last decade (30). Randomized trials have demonstrated the efficacy and safety of DOAC in patients undergoing a cardiac implantable electronic device procedure (CIED). However, there is limited real-world data. In chapter 5 we evaluated clinically significant pocket hematoma and any systemic thromboembolic complication < 30 days after surgery of consecutive patients with AF undergoing an elective CIED procedure between January 2016 and June 2019 (31). Two-hundred eighty-three procedures were performed in patients with AF using oral anticoagulation. One-third of the procedures were performed under interrupted DOAC and the remainder under continued VKA. The DOAC group was younger, had less chronic renal disease, more paroxysmal AF, and a lower HAS-BLED score. The VKA group more often underwent a generator change only, in comparison to the DOAC group. There was no significant difference in clinically significant pocket hematoma between the VKA and DOAC groups. No thromboembolic events were reported for both groups. We found that in patients with AF undergoing an elective CIED procedure, the risk of a pocket hematoma and a systemic thromboembolic event is comparably low when using either interrupted DOAC or continued VKA. Another important complication of a CIED procedure is the risk of a pocket infection. It is associated with increased mortality risk and substantial morbidity (32, 33). A pocket infection may necessitate device and lead extraction to prevent endocarditis, which leads to a significant burden for the patient and high health care costs. In reducing the risk of infections the use of antibiotic prophylaxis, chlorhexidine skin preparation, delaying the procedure in case of fever, avoidance of heparin bridging, avoidance of pocket hematoma, the use of strict sterile techniques, and having experienced operators are important preventive measures (34). 10
RkJQdWJsaXNoZXIy MTk4NDMw