Bridging Anticoagulation Therapy Research Articles

Open resection for a large iatrogenic radial artery pseudoaneurysm. Case report.

Introduction and importanceWe present the case in which a large symptomatic pseudoaneurysm (PSA), 6 × 5 cm, with one year of evolution on the path of the right radial artery (RRA) appeared after its punction and cannulation for performing cardiac catheterism in an atrial fibrillation (AF) indefinite anticoagulated patient. Diagnosis and surgical planning were consolidated only by using color duplex ultrasound (CDU), contrasted images were not indicated.The open surgical management was performed during a short-time supraclavicular blockade of peripheral nerves without stopping nor bridging anticoagulant therapy. Complete excision of the deforming mass with no blood loss, decompression of the adjacent structures and direct closure of the arterial defect without compromising of its lumen and path were also achieved.Case presentationA 74-year-old, Hispanic male patient and former smoker underwent coronary catheterization for thoracic typical pain. One year after, he is admitted for move restrictive pain in distal right forearm and hand paresthesia related to a rapidly growing right radial artery PSA of 6 cm in diameter where the indefinite anticoagulation, indicated for chronic AF, confers a risk of major bleeding.After clinic and exclusive CDU assessing, the patient granted us written authorization for performing an open surgery.One year follow up showed an asymptomatic patient with no RRA residual lesions.Clinical discussionAlthough contrasted are the preferred diagnosis methods when arterial issues are suspected especially angiography since, when indicated, the endovascular treatment may be performed immediately after diagnosis. The CDU performed with a high-sensitivity transducer is the image of choice for an immediate differential diagnosis (Meola et al., 2021 [1]). In addition, it allowed us to see both, the particular PSA inside structure and the patency of ipsilateral ulnar artery, necessary details to propose the successful open surgical treatment finally conducted.ConclusionVascular and trauma surgeons should be trained to ensure the correct diagnosis based on preexisting medical conditions, clinical findings and those provided by CDU in order to offer an appropriate and definitive management to peripheral vascular iatrogenic lesions with potential bleeding risk, especially in anticoagulated patients. Since large limb deforming PSAs are recommended to be excided through open access, they should also be trained to perform it without additional risks nor sequelae.Since the number of AF patients is increasing worldwide, main aspects on anticoagulation therapy have to be taught to every surgical team.

Periprocedural management and clinical outcomes of invasive procedures after venous thromboembolism: from the COMMAND VTE registry.

Anticoagulation therapy is prescribed for the prevention of recurrence in patients with venous thromboembolism, which could be temporarily interrupted during invasive procedures. The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic VTE in Japan between January 2010 and August 2014. We identified patients who underwent invasive procedures during the entire follow-up period and evaluated periprocedural managements and clinical outcomes at 30days after invasive procedures. During a median follow-up period of 1213 (IQR: 847-1764) days, 518 patients underwent invasive procedures with the cumulative incidences of 5.8% at 3months, 11.1% at 1year, and 24.0% at 5years. Among 382 patients in high bleeding-risk category of invasive procedures, anticoagulation therapy had been discontinued already in 62 patients (16%) and interrupted temporarily in 288 patients (75%) during the invasive procedures with bridging anticoagulation therapy with heparin in 214 patients (56%). Among 80 patients in low bleeding-risk category, anticoagulation therapy had been already discontinued in 15 patients (19%) and interrupted temporarily in 31 patients (39%) during invasive procedure with bridging anticoagulation therapy with heparin in 17 patients (21%). At 30days after the invasive procedures, 14 patients (2.7%) experienced recurrent VTE, while 28 patients (5.4%) had major bleeding. This study elucidated the real-world features of peri-procedural management and prognosis in patients with VTE who underwent invasive procedures during follow-up in the large multicenter VTE registry. The 30-day incidence rates of recurrent VTE and major bleeding events were 2.7% and 5.4%.

Periprocedural anticoagulation in AF cryoballoon ablation in a nationwide registry: no difference in complication rates between strategies

Abstract Background Standard treatment for patients with atrial fibrillation is pulmonary vein isolation (PVI). There are two widely adopted methods for PVI - cryoballon ablation (CBA) and radiofrequency (RF) ablation. There are several randomized studies evaluating different periprocedural anticoagulation strategies in patients undergoing PVI, and those mainly related to RF ablation procedures. However, there is a lack of data on safety of different anticoagulation strategies in CBA. Purpose To analyze the current anticoagulation approaches in patients undergoing cryoballoon ablation, the incidence and types of hemorrhagic and thromboembolic periprocedural events. The analysis was performed on data from the National cryoballoon AF ablation registry (NCT03040037). Methods Nineteen centers prospectively entered data into a web-based platform. The full data on AC therapy was available in 719 subjects. The specialists evaluated ischemic events clinically, and those included stroke, transient ischemic attack, pulmonary embolism or extracranial systemic embolism. Major bleedings were registered and classified according to the ISTH criteria. Results The mean CHA2DS2-VASc score was 2.0±1.4; mean BMI 29.5±4.8; mean GFR 92±28.9 ml/min. Periprocedurally, 574 (79.8%) subjects received direct oral anticoagulants (DOACs), 113 (15.7%) anti-vitamin K drugs (mainly warfarin); 16 (2%) patients received antiplathelet therapy. Uninterrupted DOAC therapy was used in 251 (34.9%) cases. Uninterrupted warfarin therapy was used in 36 (2%) patients. Bridging therapy was used in 325 (45.2%) patients. The total number of major adverse events was 25 (3.5%): 24 of them hemorrhagic and 1 transient ischemic attack (1 female patient on rivaroxaban with bridging). Five (0.7%) patients had hemopericardium: 3 - on uninterrupted rivaroxaban, 1 – rivaroxaban with bridging, 1 – interrupted apixaban. Seventeen (2.5%) patients had groin vascular complications and 1 -hemoptysis. Three patients died within 30 days following CBA from non-cardiovascular causes. There were no statistically significant differences in complications between patients receiving different periprocedural anticoagulation. Conclusions About 45% of patients referred for CBA receive bridging anticoagulation therapy in the periprocedural period. Although this is not in line with the current guidelines, we found no meaningful difference in complication rates between different anticoagulation approaches. CBA might be associated with different from RF ablation safety profile and requires randomized trials on periprocedural anticoagulation. Funding Acknowledgement Type of funding source: Other. Main funding source(s): RF President's council grant

Bridging Anticoagulation with Mechanical Heart Valves: Current Guidelines and Clinical Decisions.

The management of patients with mechanical heart valves who require surgery or invasive procedures is a common clinical scenario in contemporary practice. The risk of thromboembolism versus the risk of bleeding is the foundation of optimal patient care. Randomized, controlled trials are not available; yet, there is a wealth of experience to guide best practice. Current guidelines represent a compilation of data from trials of atrial fibrillation and expert opinion. Results from the PERI-OP trial of patients with either a mechanical heart valve, atrial fibrillation, or atrial flutter requiring interruption of oral anticoagulant therapy for surgery will inform clinical practice. Patient-specific factors and valve-specific factors are paramount when deciding whether a period of anticoagulant therapy interruption is safe. Similarly, the safety and efficacy of bridging anticoagulant therapy and the optimal time after surgery for restarting oral anticoagulants is vital to optimal patient care.

Case report: Large ovarian cyst causing limb ischaemia

We present and case of large ovarian cyst causing a complete occlusion of the pelvic vessels. 53-year-old female complained of acute ischaemia of her lower limbs 5 days after minor limb injury. She was treated as cellulitis initially. Then five days later suffered from severe limbs pain; no bridging anticoagulation therapy was initiated. CT angiogram showed showed occlusion of all crural arteries on both sides. This was due to compression and pressure of large right ovarian cyst. The patient has amputation of the right limb. This case demonstrate importance of early recognition for large intra-abdominal causes for vascular complications.

Microfluidic Point-of-Care Ecarin-Based Clotting and Chromogenic Assays for Monitoring Direct Thrombin Inhibitors

Direct thrombin inhibitors (DTIs), such as bivalirudin and dabigatran, have maintained steady inpatient and outpatient use as substitutes for heparin and warfarin, respectively, because of their high bioavailability and relatively safe “on-therapy” range. Current clinical methods lack the capacity to directly quantify plasma DTI concentrations across wide ranges. At present, the gold standard is the ecarin clotting time (ECT), where ecarin maximizes thrombin activity and clotting time is evaluated to assess DTIs’ anticoagulation capability. This work focused on the development of a microfluidic paper analytic device (µPAD) that can quantify the extent of anticoagulation as well as DTI concentration within a patient’s whole blood sample. Capillary action propels a small blood sample to flow through the nitrocellulose paper channels. Digital images of whole blood migration are then captured by our self-coded Raspberry Pi and/or the Samsung Galaxy S8 smartphone camera. Both the flow length and the blue absorbance from the plasma front on the μPAD were measured, allowing simultaneous, dual assays: ecarin clotting test (ECT) and ecarin chromogenic assay (ECA). Statistically significant (p < .05) changes in flow and absorbance were observed within our translational research study. Currently, there are no quantitative, commercially available point-of-care tests for the ECT and ECA within the United States. Both the ECT and ECA assays could be instrumental to differentiate between supratherapeutic and subtherapeutic incidents during bridging anticoagulant therapy and limit the unwarranted use of reversal agents.

Comparison of safety between continued warfarin therapy and bridging anticoagulation therapy in patients undergoing coronary intervention

Objective: To compare the safety of continued warfarin therapy and bridging anticoagulation therapy during hospital stay in patients undergoing percutaneous coronary intervention (PCI). Methods: We retrospectively analyzed patients on warfarin therapy referred for PCI in Beijing Anzhen Hospital from January 2008 to December 2016. The patients were divided into continued warfarin therapy (n=195) or bridging anticoagulation therapy (n=311) groups. After Propensity Score Matching, data from matched patients (n=123 in each group) were analyzed. Bleeding complications and major adverse cardiac events including death, myocardial infarction, target vessel revascularization, and stent thrombosis were assessed. Results: There were no significant difference in the rate of death (2.4%(3/123) vs. 1.6%(2/123),P=0.54), acute myocardial infarction (4.1%(5/123) vs. 4.9%(6/123), P=0.78),re-revascularization (0.8%(1/123) vs. 1.6%(2/123),P=0.16), stent thrombosis (1.6%(2/123) vs. 1.6%(2/123),P=1.00) and stroke between the two groups. Prevalence of minor bleeding complications was significantly higher in the bridging therapy group (15.4%(19/123) vs. 9.8%(12/123),P=0.01). Rate of access-site complications (hematoma:4.1%(5/123) vs. 2.4%(3/123),P=0.20; pseudoaneurysm:2.4%(3/123) vs. 2.4%(3/123),P=1.00; arteriovenous fistula:0.8%(1/123) vs. 1.6%(2/123),P=0.09; and retroperitoneal hematoma:0(0/123) vs. 0.8%(1/123),P=0.23) were similar between the two groups. Conclusion: For patients receiving chronic warfarin therapy, the uninterrupted oral anticoagulant treatment is as safe as bridging therapy in PCI patients.

SAFETY AND EFFICACY OF CONTINUOUS ADMINISTRATION OF ANTITHROMBOTIC DRUGS DURING TRANSURETHRAL RESECTION OF BLADDER TUMORS

(Objectives) We evaluated the safety and efficacy of continuous administration of antithrombotic drugs during transurethral resection of bladder tumors (TURBT). (Methods) We performed a retrospective review of 351 TURBT procedures performed at our institute from April 2011 to October 2015. Among these, antithrombotic drugs were continued in 31 TURBT cases throughout their perioperative period (continuation group), antithrombotic drugs were discontinued in 26 TURBT cases (discontinuation group), and bridging anticoagulation therapy with heparin after interruption of antithrombotic drugs was performed in 4 TURBT cases (heparin bridging group). The safety and efficacy of continuous administration of antithrombotic drugs during TURBT was evaluated by comparing the rate of perioperative complications, median operative time, duration of hematuria, urethral catheter placement, duration of stay after surgery, and by comparing the duration of stay among the three groups. (Results) The median operative time was 40.0 min in the continuation group, 39.0 min in the discontinuation group, and 31.0 min in the heparin bridging group with no significant differences. There were no significant differences in the median duration of hematuria (1.00 days vs. 1.00 days vs. 1.00 days), urethral catheter placement (3.00 days vs. 2.50 days vs. 2.00 days), or stay after TURBT (4.00 days vs. 3.50 days vs. 3.00 days) among the continuation, discontinuation, and heparin bridging groups. The median duration of stay was 6.00 days in the continuation group, 7.00 days in the discontinuation group, and 16.0 days in the heparin bridging group with significant differences between the continuation group vs. the heparin bridging group and the discontinuation group vs. the heparin bridging group. The rate of complications was 6 (19.4%) in the continuation group and 3 (11.5%) in the discontinuation group with no significant differences. However, a serious complication, cerebral infarction leading to hemiplegia, occurred in the discontinuation group. (Conclusion) Continuous administration of antithrombotic drugs during TURBT is considered to be safe and useful because it may prevent serious thromboembolism without adversely affecting the perioperative course.

Bridging Anticoagulation After Mechanical Aortic Heart Valve Replacement: A Questionable Routine

This retrospective single-center study evaluates differences in bleeding and thrombotic events between a homogenous group of patients undergoing mechanical aortic valve replacement who either received or did not receive intravenous unfractionated heparin or subcutaneous low-molecular weight heparin as bridging strategy to warfarin therapy. Clinical data on a total of 158 patients undergoing mechanical aortic valve replacement at our center between 2001 and 2014 were collected. Patients were grouped according to postoperative anticoagulation strategy: warfarin only (n= 53) and warfarin plus heparin bridge (n= 105). The outcomes of interest were bleeding event and thromboembolic event recorded during hospital stay. Patients' baseline characteristics were comparable between the two groups except for preoperative atrial fibrillation, which was more common in the warfarin plus heparin group than the warfarin group (p= 0.04). There were significantly more bleeding complications in the warfarin plus heparin group versus warfarin group as evidenced by higher rates of pericardial effusions (24% versus 8%, p= 0.02) and reoperation for bleeding (8% versus 0%, p= 0.05). All observed thromboembolic events (n= 4) occurred in the warfarin plus heparin group (p= 0.55). Logistic regression analysis identified group assignment (warfarin plus heparin versus warfarin only) to be significantly associated with the odds of bleeding (odds ratio 4.46, 95% confidence interval:1.42 to 14.02, p= 0.01). Bridging anticoagulation therapy increases the chances of bleeding in the postoperative phase for mechanical aortic valve replacement patients. Owing to low incidence, no statistically significant difference was detected for thromboembolic event rates.

Acute coronary syndromes

Acute coronary syndromes

Early postoperative bridging anticoagulation after mechanical heart valve replacement: a systematic review and meta‐analysis

To perform a systematic review and meta-analysis of studies evaluating anticoagulation during the early postoperative period following mechanical heart valve implantation. Five literature databases were searched to assess the rates of bleeding and thromboembolic events among patients receiving oral anticoagulation (OAC), both with and without bridging anticoagulation therapy with unfractionated heparin (UFH) or subcutaneous low molecular weight heparin (LMWH). The studies' results were pooled via a mixed effects meta-analysis. Heterogeneity (I(2) ) and publication bias were both evaluated. Twenty-three studies including 9534 patients were included. The bleeding rates were 1.8% (95% confidence interval CI1.0-3.3) in thegroup receiving OAC, 2.2% (95%CI0.9-5.3) in the OAC+UFH group, and 5.5% (95%CI2.9-10.4) in the OAC+LMWH group (P=0.042). The thromboembolic event rate was 2.1% (95%CI1.5-2.9) in the group receiving OAC, as compared with 1.1% (95%CI0.7-1.8) when the bridging therapy groups were combined as follows: OAC+UFH and OAC+LMWH (P=0.035). Most of the analyses showed moderate heterogeneity and negative test results for publication bias. Bridging therapy following cardiac valve surgery was associated with a lower thromboembolic event rate, although the difference was small, with considerable overlap of the CIs. Direct comparisons are missing. Bridging therapy with UFH appears to be safe; however, this observation has a risk of bias. Early bridging therapy with LMWH appears to be associated with consistently high bleeding rates across multiple analyses. On the basis of the quality of the included studies, more trials are necessary to establish the clinical relevance of bridging therapy and the safety of LMWH.

Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

BackgroundIt is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding.MethodsWe performed a randomized, double-blind, placebo-controlled trial in which, after perioperative interruption of warfarin therapy, patients were randomly assigned to receive bridging anticoagulation therapy with low-molecular-weight heparin (100 IU of dalteparin per kilogram of body weight) or matching placebo administered subcutaneously twice daily, from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. Warfarin treatment was stopped 5 days before the procedure and was resumed within 24 hours after the procedure. Follow-up of patients continued for 30 days after the procedure. The primary outcomes were arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding.ResultsIn total, 1884 patients were enrolled, with 950 assigned to receive no bridging therapy and 934 assigned to receive bridging therapy. The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (risk difference, 0.1 percentage points; 95% confidence interval [CI], −0.6 to 0.8; P=0.01 for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority).ConclusionsIn patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health; BRIDGE ClinicalTrials.gov number, NCT00786474.)

Antithrombotic Strategies in Perioperative Period

Antithrombotic therapy (Warfarin, Aspirin,Clopidogrel etc.) are routinely used in prevention and treatment of various cardiovascular diseases. In patients who are having a surgical or other invasive procedure, interruption of antithrombotic therapy is typically required to minimize the risk for perioperative bleeding. It involves balancing the risk of periprocedural bleeding with continued treatment against the thrombotic risk with suspension of treatment and use of bridging anticoagulation therapy. The need for bridging is driven by patients’ estimated risk for thromboembolism and the bleeding risk of invasive procedure. Treatment with subcutaneous low-molecular- weight heparin or intravenous unfractionated heparin at a therapeutic dose before and after the procedure recommended as bridging anticoagulation therapy. DOI: http://dx.doi.org/10.3329/uhj.v9i1.19511 University Heart Journal Vol. 9, No. 1, January 2013; 47-51

Suspected intraoperative formation of left atrial thrombus in a patient with atrial fibrillation receiving bridging anticoagulation therapy

We present a patient with atrial fibrillation (AF) in whom a left atrial (LA) thrombus might have formed during laparotomy despite bridging anticoagulation therapy. No evidence of thrombus was detected by transesophageal echocardiography (TEE) at the start of surgery; however, a thrombus measuring 13 × 10 mm was found in the LA appendage by the end of the procedure, suggesting that thrombus might develop intraoperatively in patients with AF even when bridging anticoagulation is properly established. Intraoperative TEE can assist in detecting intracardiac thrombus in patients with AF regardless of their anticoagulation status and provides a tool for intervention to prevent systemic embolization.

Bridging Therapy: A Challenging Area in the Management of Patients with Atrial Fibrillation

As part of the comprehensive approach to the management of atrial fibrillation (AF), improving prevention from stroke and thromboembolism (TE) has a high priority [1]. Whilst it is accepted that chronic prophylaxis is valuable, occasional interruption of oral anticoagulation (until recently, warfarin) necessitates bridging therapy with a parenteral anticoagulant, and this is where uncertainties arise [2, 3]. Bridging therapy is usually used for those patients who undergo the initiation or interruption of vitamin K antagonist (VKA) therapy, or have subtherapeutic international normalized ratio (INR) values. The decision regarding bridging therapy should be based on a careful assessment of the risks for TE and bleeding [4]. However, there are limited data about the use of bridging therapy in patients with AF. A study published recently by Smoyer-Tomic et al. [5] found that amongst 3037 inpatients with AF for medical (70%) or surgical admissions (30%), there were 1944 (64%) patients who received bridging therapy. Given the exclusion of pulmonary embolism (PE) and cardiac surgery in this observational study, the real rate of bridging therapy could possibly be even higher among inpatients with AF. Although definite reasons for bridging are unknown given the limitations of observational data from an administrative claims dataset, most patients would likely have received bridging therapy along with initiation of warfarin as many had no evidence of warfarin use in the 6-month period before hospitalization. Also, bridged patients were more likely to have co-morbid conditions, including atrial flutter, ischemic stroke/transient ischemic attack (TIA)/cerebrovascular disease, and acute myocardial infarction (AMI). In their study, the AF patients who received bridging therapy had a mean CHA2SD2-VASc score of 3.5, consistent with a high risk of TE. It was notable that length of stay (LOS) was longer for bridged than non-bridged patients. This aspect may reflect the patients’ co-morbidities of such ‘more complex’ patients. Indeed, for the VKA-naive patient at high risk of thromboembolism undergoing initiation of VKA therapy, a ‘bridge’ anticoagulant should be considered to minimize the delay in achieving therapeutic anticoagulation. The ‘bridge’ is administered parentally, thereby providing a near-immediate anticoagulant effect. The bigger challenge for bridging anticoagulant therapy is amongst the chronically anticoagulated patients, who need to temporarily interrupt VKAs because of special situations, e.g. catheter ablation, implantation of a pacemaker or an implantable cardioverter-defibrillator (ICD), percutaneous coronary intervention (PCI), or surgery. The invasive procedure may increase the risk of bleeding, whilst on the other hand interruption of VKAs may confer an increased risk of TE. Besides the risk for stroke, the risk for major adverse cardiac events and stent thrombosis might also increase [6–8]. Thus, clinicians would need to weigh the risk of TE This article was intended for inclusion in Volume 12 Number 6 but was inadvertently omitted as the journal transitioned to a new production system.

Thyroid Surgery and Anticoagulation: Survey of Practice of Endocrine Surgeons in Australia

ABSTRACT Few studies specifically address management of venous thromboembolism (VTE) prophylaxis and bridging anticoagulation therapy in patients undergoing thyroid surgery. A survey about perioperative management of thromboprophylaxis was sent to Australian Endocrine Surgeons. Responses were tabulated and graphed; a p-value of < 0.05 was considered statistically significant. Survey responses showed a large broad spectrum of practice regarding thromboprophylaxis, bridging therapy and cessation of anticoagulant medication. While anticoagulant prophylaxis in thyroid surgery appears to be relatively safe, there is a theoretical risk of catastrophic bleeding complications; according to this survey of Australian Endocrine Surgeons, thromboembolic events are uncommon complications of thyroid surgery. How to cite this article Verma KP, Gorelik A, Miller JA. Thyroid Surgery and Anticoagulation: Survey of Practice of Endocrine Surgeons in Australia. World J Endoc Surg 2013;5(1):6-11.

Bridging Therapy: A Challenging Area in the Management of Patients with Atrial Fibrillation.

As part of the comprehensive approach to the management of atrial fibrillation (AF), improving prevention from stroke and thromboembolism (TE) has a high priority [1]. Whilst it is accepted that chronic prophylaxis is valuable, occasional interruption of oral anticoagulation (until recently, warfarin) necessitates bridging therapy with a parenteral anticoagulant, and this is where uncertainties arise [2, 3]. Bridging therapy is usually used for those patients who undergo the initiation or interruption of vitamin K antagonist (VKA) therapy, or have subtherapeutic international normalized ratio (INR) values. The decision regarding bridging therapy should be based on a careful assessment of the risks for TE and bleeding [4]. However, there are limited data about the use of bridging therapy in patients with AF. A study published recently by Smoyer-Tomic et al. [5] found that amongst 3037 inpatients with AF for medical (70%) or surgical admissions (30%), there were 1944 (64%) patients who received bridging therapy. Given the exclusion of pulmonary embolism (PE) and cardiac surgery in this observational study, the real rate of bridging therapy could possibly be even higher among inpatients with AF. Although definite reasons for bridging are unknown given the limitations of observational data from an administrative claims dataset, most patients would likely have received bridging therapy along with initiation of warfarin as many had no evidence of warfarin use in the 6-month period before hospitalization. Also, bridged patients were more likely to have co-morbid conditions, including atrial flutter, ischemic stroke/transient ischemic attack (TIA)/cerebrovascular disease, and acute myocardial infarction (AMI). In their study, the AF patients who received bridging therapy had a mean CHA2SD2-VASc score of 3.5, consistent with a high risk of TE. It was notable that length of stay (LOS) was longer for bridged than non-bridged patients. This aspect may reflect the patients’ co-morbidities of such ‘more complex’ patients. Indeed, for the VKA-naive patient at high risk of thromboembolism undergoing initiation of VKA therapy, a ‘bridge’ anticoagulant should be considered to minimize the delay in achieving therapeutic anticoagulation. The ‘bridge’ is administered parentally, thereby providing a near-immediate anticoagulant effect. The bigger challenge for bridging anticoagulant therapy is amongst the chronically anticoagulated patients, who need to temporarily interrupt VKAs because of special situations, e.g. catheter ablation, implantation of a pacemaker or an implantable cardioverter-defibrillator (ICD), percutaneous coronary intervention (PCI), or surgery. The invasive procedure may increase the risk of bleeding, whilst on the other hand interruption of VKAs may confer an increased risk of TE. Besides the risk for stroke, the risk for major adverse cardiac events and stent thrombosis might also increase [6–8]. Thus, clinicians would need to weigh the risk of TE This article was intended for inclusion in Volume 12 Number 6 but was inadvertently omitted as the journal transitioned to a new production system.

The hospital pharmacist as a member of a multidisciplinary team to manage anticoagulation before and after elective surgery

BackgroundInaccurate anticoagulant reconciliation at the preadmission stage of an elective surgical patient-care pathway can lead to either thromboembolic incidents on admission or could increase the risk of perioperative bleedings. The...

Continuing warfarin therapy is superior to interrupting warfarin with or without bridging anticoagulation therapy in patients undergoing pacemaker and defibrillator implantation

Current guidelines recommend stopping oral anticoagulation and starting bridging anticoagulation with intravenous heparin or subcutaneous enoxaparin when implanting a pacemaker or defibrillator in patients at moderate or high risk for thromboembolic events. A limited body of literature suggests that device surgery without cessation of oral anticoagulation may be feasible. The purpose of this study was to evaluate the safety of device surgery in orally anticoagulated patients without interrupting warfarin therapy. We performed a retrospective study of 459 consecutive patients on chronic warfarin therapy who underwent device surgery from April 2004 to September 2008. Warfarin was continued in 222 patients during the perioperative period. Warfarin was temporarily held and bridging therapy administered in 123 patients. Warfarin was temporarily held without bridging therapy in 114 patients. There were no significant differences with regard to age, sex, or risk factors for thromboembolism in the three groups. Patients who continued taking warfarin had a lower incidence of pocket hematoma (P = .004) and a shorter hospital stay (P <.0001) than did patients in the bridging group. Holding warfarin without bridging is associated with a higher incidence of transient ischemic attacks (P = .01). Temporarily interrupting anticoagulation is associated with increased thromboembolic events, whereas cessation of warfarin with bridging anticoagulation is associated with a higher rate of pocket hematoma and a longer hospital stay. Continuing warfarin with a therapeutic international normalized ratio appears to be a safe and cost-effective approach when implanting a pacemaker or defibrillator in patients with moderate to high thromboembolic risk.

Aortic Thrombosis Due to a Giant Ovarian Cyst

We describe a patient who presented with a giant ovarian cyst causing a complete occlusion of the distal abdominal aorta. An 86-year-old patient presented with acute ischaemia of her lower limbs 3 days after a transurethral resection of a bladder tumour (TURT). She refused treatment for her giant ovarian cyst. The administration of Sintrommitis® was ceased 3 days preoperatively; no bridging anticoagulation therapy was initiated. A computed tomography (CT) angiogram showed a thrombotic occlusion of the distal aorta. We believe this to have been caused by pressure from the giant ovarian cyst. The patient died 2 days later. This case illustrates that awareness is warranted for vascular complications in patients, with a giant intra-abdominal cyst or tumour, undergoing abdominal or pelvic surgery.