Chapter 6 92 assist devices, adult congenital heart disease, lead extraction, inherited cardiac disease, and pediatric cardiac surgery. 2.2. Anticoagulation regimen Patients using direct oral anticoagulants (DOACs) discontinued their drug 24–48 h before surgery depending on their renal function. All DOACs were restarted 24 h after the end of surgery, unless stated otherwise by the operator. In patients using vitamin K antagonists (VKA), the target international normalized ratio was 2.0 to 2.5 in the morning of the procedure. Patients with continued VKA usually attained to their regular dosing schedule. Heparin bridging was avoided if possible. 2.3. Antibiotic treatment regimen All patients received systemic antibiotic prophylaxis within 1 h of the procedure. This was either a single dose of intravenous cefazolin (2 g) or intravenous clindamycin (600–900 mg depending on weight) if patients were allergic to beta-lactam antibiotics (i.e., penicillin, cephalosporins). Vancomycin was reserved for patients with an allergy to both cefazoline and clindamycin. This local antibiotic regimen was based on the national guidelines for antibiotic use in the Netherlands. We postponed CIED procedures in patients who had a fever or high C-reactive protein at the day of their surgery. No postoperative antibiotic therapy was routinely given. 2.4. Peri-procedural setting CIED procedures were performed in a catheterization lab which is a sterile environment which complies with the requirements of an operating room Class 2 according to the Dutch Infection Prevention Taskforce guidelines. This includes the use of two semi-restricted zones and tightly controlled ranges for temperature, pressure (i.e., positive pressure of at least 5 Pa from zone A to B), relative humidity, and ventilation rates (i.e., minimum of 10 total air exchanges per hour, use of air filter using HEPA). The number of staff was kept to a minimum and usually consisted of a physician, scrub nurse, circulating nurse, and a CIED technician. All procedures were performed or supervised by an EHRA-certified cardiac device specialist with a large experience in CIED implantations. CIED procedures were also performed by fellows. After a surgical scrub, the operator(s) and scrub nurse wore a sterile gown, cap, mask, and non-powdered double gloves. The scrub nurse performed the prepping
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