Chapter 10 174 optimal implantation technique, operator experience and facilities should meet a certain standard. CIED implantations are considered low bleeding risk procedures with an incidence of bleeding of approximately 2% (30). However, pocket hematoma and CIED-related infections remain a significant concern, as this not only can cause local discomfort or pain but also may result in prolongation of hospitalisation and even re-operation on some occasions (42-44). Furthermore, a pocket hematoma increases the risk of a pocket infection (45), and consequently increased morbidity and mortality (34, 46). Therefore, mitigation of the risk of hematoma is essential and this requires meticulous attention to modifiable risk factors, good operative skills, and proper patient preparation. Modifiable risk factors for pocket hematoma include heparin bridging, concomitant antiplatelet therapy, low operator experience, and the use of a submuscular pocket (27, 47, 48). Non-modifiable risk factors include renal failure, congestive heart failure, device replacement and upgrade or lead revision procedure. In addition to these (non)modifiable risk factors, active preventive measures with gelatine-thrombin matrix sealants, like FloSeal® or Surgiflow®, can be used to effectively aid haemostasis in CIED surgery (49). Postoperative surveillance for signs of hematoma formation is essential for timely intervention. Compression with sandbags, vests or tapes can be effective as an intervention (50). Risk assessment using risk score calculators serve as a valuable tool by offering an objective means to identify high-risk patients for bleeding and infection (35, 51-53). Furthermore, it enhances communication between healthcare providers by quantifying if the selected patient is at high-risk and consequently taking appropriate preventive measures. Ideally, this is also communicated with the patient as part of the shared decision-making process. However, risk-scores like the HAS-BLED have shown limited performance in patients under a DOAC anticoagulation regimen in predicting bleeding risk. The novel ‘DOAC Score’ has a stronger predictive performance than the HAS-BLED score in patients with AF and using either apixaban, edoxaban or rivaroxaban (53) and consequently has the potential to better identify patients at risk for a pocket hematoma. This ‘DOAC Score’ assigns points for age, creatinine clearance/glomerular filtration rate, underweight status, stroke/transient ischemic attack/embolism history, diabetes,
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