DOACs in pacemaker or defibrillator surgery 79 4.1. Pocket hematoma and periprocedural anticoagulation Pocket hematoma is one of the most common complications following CIED surgery.(6) A pocket hematoma is not always benign and can be associated with prolongation of hospitalization, an increased risk of reoperation, and serious devicerelated infection (8,10,11,17). Therefore, prevention of pocket hematoma is important and this requires meticulous attention to modifiable risk factors, good operative skills and proper patient preparation. Risk factors for device pocket hematoma includes older age, renal failure, congestive heart failure, low operator experience, concomitant antiplatelet therapy, device replacement, lead revision, and heparin bridging (4,15,17-23). In patients using VKA, continued VKA is preferred over heparin bridging as the last is associated with a higher risk of pocket hematoma and prolonged hospital stay (4,6,19). Currently, most centers prefer either a continued VKA regimen or interrupt VKA without heparin bridging in case of a low CHA2DS2VASc score (<3) in patients with AF (15). With regard to periprocedural DOAC, the 2021 ESC guidelines on Cardiac Pacing and Cardiac Resynchronization Therapy and a 2021 EHRA expert consensus statement have no specific preference for either continued or interrupted DOAC in patients undergoing CIED surgery (6,7). The BRUISE CONTROL-2 trial demonstrated a similar low risk for clinically significant pocket hematoma in patients using either continued or interrupted DOAC (2.1% in both groups).(3) Several singlecenter studies have demonstrated a similar low risk of clinically significant pocket hematoma when using continued DOAC,(24,25) however, a recent meta-analysis demonstrated a numerically higher incidence of bleeding complications in patients who continued DOAC (14). Furthermore, many centers still prefer a interrupted DOAC regimen (15). Therefore, it is interesting to know in a real-world population how an interrupted DOAC regimen would compare to the widely accepted continued VKA regimen regarding the incidence of pocket hematoma. It should be noted that we excluded patients who used concomitant antiplatelet therapy to prevent bias, as it is wellestablished that concomitant antiplatelet therapy in anticoagulated patients is associated with a two-fold higher risk of clinically significant pocket hematoma (23). We observed a low incidence of clinically significant pocket hematoma; this was 5
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