Periprocedural Anticoagulation Research Articles

Management of patients receiving novel antithrombotic treatment in endodontic practice: Review and clinical recommendations

Cardiovascular diseases are a major component of non-communicable diseases and death, with thrombosis constituting the most common underlying pathosis of the three major cardiovascular disorders: ischaemic heart disease (acute coronary syndrome), stroke and venous thromboembolism (VTE). The introduction of direct oral anticoagulants (DOACs) in recent years has necessitated a more complex approach to periprocedural and perioperative anticoagulation management and the need for revised management strategies and protocols. Currently, patients taking classic oral anticoagulants are advised to stop taking the drugs and have their INR values checked 72h prior to dental surgery (e.g., apical surgery, tooth extraction, and periodontal surgery) and checked again 24h prior to the procedure to ensure it is within the therapeutic range. However, the current incorporation of these novel DOACs in routine medical practice requires changes in the way patients are managed preoperatively in dentistry, and specifically in endodontic surgery. The methodology applied in this review included searching for relevant articles in the PubMed database using keywords listed in the Entree Terms databases. Articles published on human blood clotting mechanism, antithrombotic drugs, as well as treatment guidelines and recommendations for dentistry were retrieved. In addition, textbooks and guidelines that may not have surfaced in the online search were searched manually. The aim of this paper was to review the mechanisms of action of classic and novel antithrombotic medications and their impact on endodontic treatment and the management of local haemostasis in endodontics.

Outcome of transvenous lead extraction in patients on minimally interrupted periprocedural direct oral anticoagulation therapy.

Direct oral anticoagulants (DOACs) have increasingly been used for several indications for systemic anticoagulation in patients with cardiac implantable electronic devices (CIEDs). The optimal management of anticoagulation therapy in patients undergoing transvenous lead extraction (TLE) procedures remains uncertain. The aim of this study was to evaluate the feasibility and safety of TLE during minimally interrupted DOAC therapy. This is a single-center retrospective study of all patients who underwent TLE of a pacemaker or implantable cardioverter-defibrillator lead while on DOAC therapy. In patients deemed to be at high thromboembolic risk, the last DOAC dose was administered the morning of the day before the procedure (regardless of the type of DOAC) and was restarted as soon as possible after the procedure, without bridging with parenteral anticoagulation. During the study period, a total of 84 patients underwent TLE while on minimally interrupted DOAC therapy (54% female, mean age: 74 ± 12 years). TLE was attempted for 161 leads, with a median lead dwell time of 61 months (interquartile range, 38-101). Complete procedural success was achieved for 156 leads (96.9%) and partial success for additional two leads (1.2%). One patient developed RV perforation and required pericardiocentesis and blood transfusion, but no surgical repair. Two patients developed pocket hematomas requiring invasive evacuation. No systemic or venous thromboembolic events were observed. There was no in-hospital mortality. In selected CIED patients at high risk for thromboembolism, TLE during minimally interrupted DOAC therapy may be considered when performed at experienced centers.

Left atrial \u0131ntramural hematoma after radiofrequency catheter ablation of left lateral accessory pathway

We report a case of left atrial hematoma after ablation of left lateral concealed accessory pathway. A 46-year-old male patient experienced chest pain after radiofrequency ablation. Transthoracic echocardiography and computed tomography revealed the intramural mass consistent with hematoma in the left atrium. He was hemodynamically stable, and conservative approach was decided. Atrioventricular groove is a vulnerable part of left atrium, and ablation of left free wall accessory pathway may require targeting both atrial and ventricular surfaces of the mitral annulus. Avoidance of forceful catheter manipulation during the electrophysiological procedure is important for prevention of this complication. Optimal periprocedural anticoagulation might reduce the risk of procedure-related thromboembolic complications, but electrophysiologists should always pay attention to an intramural hematoma that may occur after radiofrequency catheter ablation.

Incidence and risk factors of post-operative cognitive decline after ablation for atrial fibrillation

BackgroundCatheter ablation is widely used in atrial fibrillation (AF) management. In this study, we are aimed to investigate the incidence of postprocedural cognitive decline in a larger population undergoing AF ablation under local anesthesia, and to evaluate the associated risk factors.MethodsThis study included 287 patients with normal cognitive functions, with 190 ablated AF patients (study group) and 97 AF patients who are awaiting ablation (practice group). We assessed the neuropsychological function of each patient for twice (study group: 24 h prior to ablation and 48 h post ablation; practice group: on the day of inclusion and 72 h later but before ablation). The reliable change index was used to analyze the neuropsychological testing scores and to identify postoperative cognitive dysfunction (POCD) at 48 h post procedure. Patients in the study group accepting a 6-month follow up were given an extra cognitive assessment.ResultsAmong the ablated AF patients, 13.7% (26/190) had POCD at 48 h after the ablation procedure. Multivariable analysis revealed that, a minimum intraoperative activated clotting time (ACT) < 300 s (OR 3.82, 95% CI 1.48–9.96, P = 0.006) and not taking oral anticoagulants within one month prior to ablation(OR 10.35, 95% CI 3.54–30.27, P < 0.001) were significantly related to POCD at 48 h post-ablation. In 172 patients of the study group accepting a 6-month follow up, there were 23 patients with POCD at 48 h post-ablation and 149 patients without POCD. The global cognitive scores were decreased in 48 h post-operation tests (0 ± 1 vs − 0.15 ± 1.10, P < 0.001) and improved significantly at 6 months post-operation (0 ± 1 vs 0.43 ± 0.92, P < 0.001). In the 23 patients with POCD at 48 h after the procedure, global cognitive performance at 6 months was not significantly different compared with that at baseline (− 0.05 ± 1.25 vs − 0.19 ± 1.33, P = 0.32), while 13 of them had higher scores than baseline level.ConclusionsIncident of POCD after ablation procedures is high in the short term. Inadequate periprocedural anticoagulation are possible risk factors. However, most POCD are reversible at 6 months, and a general improvement was observed in cognitive function at 6 months after ablation.

A Simple Quality Initiative Significantly Improves Post-Procedural Documentation of an Anticoagulation Plan After Elective Endoscopy

Anticoagulation therapy increases the risk of bleeding from endoscopic procedures. Clear documentation of a post-procedural anticoagulation plan is essential to reduce bleeding and limit unnecessary interruptions in patients’ anticoagulation. Societal guidelines provide recommendations regarding the management of peri-procedural anticoagulation and consider this a quality metric for endoscopy. In this study, we measured the rate of documentation of a post-procedural anticoagulation plan before and after the implementation of a quality initiative.

Periprocedural anticoagulation management in edxoaban patients undergoing catheter-based cardiovascular procedures: analyses of the noninterventional global EMIT study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Background The optimal periprocedural management of direct oral anticoagulants (DOAC), including edoxaban, in patients undergoing catheter-based cardiovascular procedures is unknown, and mainly based on physician opinion and experience. Purpose To assess real-world management of edoxaban in patients undergoing cardiovascular procedures, and to report their clinical events. Methods Global EMIT-AF/VTE is a prospective study of periprocedural management in edoxaban-treated patients undergoing diagnostic and therapeutic procedures. We report the data from patients undergoing cardiovascular procedures. Timing and duration of edoxaban interruption were at the treating physician’s discretion. Outcomes were collected from 5 days before until 30 days post procedure. Primary outcome was the incidence of major bleeding (MB); secondary outcomes included incidence of clinically relevant non-major bleeding (CRNMB) and acute thromboembolic events (ATE). Results Data was collected from 301 and 311 procedures with arterial or venous access, respectively. Baseline characteristics are shown in Table 1. Edoxaban was not interrupted in 36.9% of arterial and 52.7% of venous procedures. Edoxaban was interrupted pre-procedure in 41% of arterial and 32.8% of venous procedures. The median periprocedural interruption was 2 days. The overall incidence of bleeding was very low. Any bleeding was reported in 8 patients undergoing arterial and 10 patients undergoing venous procedures (2.7% and 3.2%). MB or CRNMB occurred in 2 arterial and 3 venous procedures (0.7% and 1.0%) and ATE occurred in 5 arterial and 1 venous procedure (1.7% and 0.3%, Table 1). Conclusions In this study, the periprocedural risks of bleeding and thrombotic events were low. About a third of arterial access procedures and half of venous access procedures were performed without edoxaban interruption. Arterial(n = 301) Venous(n = 311) Baseline characteristics Age, year, mean (SD)Male, n (%)Weight (kg), mean (SD) 71.9 (8.5)211 (70.1%)80.8 (16.7) 64.6 (11.1)215 (69.1%)84.1 (17.4) CrCL (mL/min), mean (SD) CHA2DS2-VASc score, mean (SD)HAS-BLED score, mean (SD) 73.5 (29.8) 3.3 (1.5)2.0 (1.0) 88.9 (35.5) 2.2 (1.5)1.3 (1.0) Edoxaban 60 mg / 30 mg, % 73% / 26% 88% / 26% Coronary heart disease, n (%) Congestive heart failure, n (%) 101 (33.6%) 58 (19.3%) 51 (16.4%) 33 (10.6%) Interruption of edoxaban, n (%) No interruption Pre-procedure only Post-procedure only Pre- and post-procedure 111 (36.9%)125 (41.5%)12 (4.0%)53 (17.6%) 164 (52.7%)102 (32.8%)8 (2.6%)37 (11.9%) Clinical events, n (%) MB or CRNMBACSStroke/Transient ischemic attackCV mortalityAll-cause mortality 2 (0.7%)2 (0.7%)3 (1.0%)1 (0.3%)2 (0.7%) 3 (1.0%) 01 (0.3%)00

Transvenous lead extraction on uninterrupted anticoagulation: A safe approach?

IntroductionCurrent guidelines advocate reviewing peri-procedural anticoagulation on individual case basis for transvenous lead extraction (TLE). We investigated the safety of TLE on uninterrupted warfarin with therapeutic INR. MethodsRetrospective registry of consecutive patients undergoing TLE on uninterrupted warfarin (Warfarin Group) across two centres. Age and sex matched controls not on anticoagulation (No-Warfarin Group) and undergoing TLE over the same time-period were included. Both groups were compared over one-year. Results121 TLEs over 18-months. 22 patients on uninterrupted anticoagulation were compared to 22 controls. Groups were well matched for baseline demographics other than INR. Warfarin group had mean INR of 2.2 ± 0.6 (range 2–3.5). Primary end point was procedural safety and efficacy. Amongst cases, 43/45 (96%) leads were removed in their entirety compared to 37/40 (93%) in controls (p = 0.66). In the cases, these included 44% defibrillator, 47% pace-sense and 9% CS leads of average duration 7yrs. There was no reported tamponade, haemothorax or procedural mortality in either group. One patient amongst cases required inotropic support while two patients amongst controls had device-site haematomas. No significant difference reported in Hb drop post-procedure or overall complication rate between the groups (p = 0.11,0.32). Cox regression showed a significant association between procedural success and device infection, number of leads extracted, serum creatinine (p = 0.03, 0.04, 0.02). Over a 1-year follow-up, there was lead displacement in one case and one control had infection of the re-implanted device. ConclusionTLE can be carried out safely in anticoagulated patients with therapeutic INRs. Larger multicentre studies are required to confirm these findings.

Impact of anemia on short-term outcomes after TAVR: A subgroup analysis from the BRAVO-3 randomized trial.

To determine the prognostic impact of anemia in patients randomized to bivalirudin or unfractionated heparin (UFH) during transcatheter aortic valve replacement (TAVR). Whether the periprocedural use of bivalirudin as compared with UFH in anemic patients undergoing TAVR has an impact on outcomes remains unknown. The BRAVO-3 trial compared the use of bivalirudin versus UFH in 802 high risk patients undergoing transfemoral TAVR for severe symptomatic aortic stenosis. Patients were stratified according to the presence (defined as hemoglobin levels <13 g/dl in men and <12 g/dl in women) or absence of anemia. The primary outcomes were net adverse cardiac events (NACE; a composite of all-cause mortality, myocardial infarction, stroke, or bleeding) and major bleeding (Bleeding Academic Research Consortium ≥3b) at 30 days. Among 798 patients with available baseline hemoglobin levels, 427 (54%) were anemic of whom 221 (52%) received bivalirudin. There were no significant differences in NACE and major bleeding at 30 days between patients with and without anemia, irrespective of the type of anticoagulant used (pinteraction =0.71 for NACE, pinteraction =1.0 for major bleeding). However, anemic patients had a higher risk of major vascular complications (adjusted OR 2.43, 95% CI 1.42-4.16, p=0.001), and acute kidney injury (adjusted OR 1.74, 95% CI 1.16-2.59, p=0.007) compared to non-anemic patients at 30 days. Anemia was not associated with a higher risk of NACE or major bleeding at 30 days after TAVR without modification of the treatment effects of periprocedural anticoagulation with bivalirudin versus UFH.

Abstract No. 522 Safety and efficacy of Angio-Seal compared with manual compression in achieving hemostasis following direct puncture of PTFE grafts

To compare the safety and efficacy of Angio-Seal to manual compression in achieving hemostasis following direct percutaneous access of polyethylene terephthalate (PTFE) vascular bypass grafts This was an IRB-approved single institution, retrospective review of all patients undergoing endovascular evaluation and/or intervention performed on a peripheral bypass graft from June 2013 to July 2020. Cases in which the percutaneous access was not gained directly into the bypass graft, the bypass graft was not composed of PTFE, or in which closure was not obtained with either Angio-Seal or manual compression (e.g., planned primary surgical closure in collaborative hybrid cases) were excluded. Demographic data including patient age, sex, and co-morbidities, as well as procedural data including the type of procedure, type of graft accessed (femoral-femoral, axillary-femoral, femoral-popliteal or femoral-distal), method of access closure, peri-procedural anticoagulation and antibiotic use, and data regarding 30-day post-procedural complications were collected. For the purposes of this study, an ‘angiogram with intervention’ broadly includes all variety of angioplasty and stenting. A total of 373 cases involving lower extremity bypass interventions were reviewed. Of these, 119 unique cases resulted in 154 direct punctures of a PTFE bypass which met criteria for analysis. This included diagnostic angiograms (n = 18 (12%)), angiography with intervention (n = 66 (43%)) and utilization of catheter-directed thrombolysis (n = 70 (45%)). 116 accesses were closed with Angio-Seal and hemostasis was achieved with manual compression in the remaining 38. Overall, the access complication rate of direct PTFE puncture was 5.2%, with a major complication rate of 2.6%. A total of 4 (3.4%) complications were reported in PTFE accesses closed with Angio-Seal. Of these, 2 (1.7%) were considered major complications, including an abscess requiring surgical drainage and post-deployment stenosis requiring repair. A total of 4 (10.5%) complications were reported following manual compression, of which 2 (5.3%) developed pseudoaneurysms necessitating repair, which were considered major complications. Of the 8 total reported complications, 6 (75%) arose after catheter-directed thrombolysis, and the remaining 2 following an intervention. No complications were reported following diagnostic angiography alone. Angio-Seal is safe and effective in achieving hemostasis following PTFE puncture and has a lower rate of overall and major complications.

Transesophageal Versus Intracardiac Echocardiogram in Patients at High-Risk for Thromboembolic Events Undergoing Atrial Fibrillation Ablation

Objective: To compare safety outcomes in patients at high-risk of thromboembolic events (TE) that underwent atrial fibrillation (AF) ablation with pre-procedural transesophageal echocardiography (TEE) versus intracardiac echocardiogram (ICE). Background: TEE is routinely performed in selected patients undergoing AF ablation, particularly in non-paroxysmal AF and high-risk of TE. Method: Patients at high-risk for TE (CHA2DS2 -VASc >2 and non-paroxysmal AF) were selected from the Montefiore Medical Center prospective AF ablation registry. Rates of left atrial and/or left atrial appendage (LA/LAA) thrombi or cerebrovascular accidents within 48 hours of the procedure and at 30 days follow-up were compared between patients that had LA/LAA screening with TEE vs. ICE. Results: A total of 231 patients [38 (16.5%) warfarin, 120 (59.1%) apixaban, 65 (28.1%) rivaroxaban, and 8 (3.5%) dabigatran] were enrolled. There were no differences between groups regarding baseline demographics. All patients had non-paroxysmal AF and the mean CHA2DS2-VASc was 4.0 {plus minus} 1.1 (TEE: 4.1 +/- 1.0; ICE: 3.9 +/- 1.1, p = 0.42). Forty patients (17.3%) had TEE prior to AF ablation. Of these patients, 14 (35%) had smoke and none (0%) had LA/LAA thrombus. In the ICE group (191 patients, 83%), none (0%) had LA/LAA thrombus or smoke. There were no TE within 48 hours of AF ablation in either group. There was one TE (stroke) in the ICE group (p=0.32) during follow up. Conclusion: TEE may not be necessary when performing AF ablation in patients at high-risk of TE if appropriate peri-procedural anticoagulation and detailed LA/LAA evaluation with ICE is implemented.

Periprocedural Anticoagulation and Antiplatelet Medications Management for Interventional Radiology Procedures

Periprocedural Anticoagulation and Antiplatelet Medications Management for Interventional Radiology Procedures

Reopening Interventional Pain Practices during the Early Phase of the COVID-19 Global Pandemic.

ObjectiveExamine how interventional pain physicians navigated the early phase of reopening practices during the coronavirus disease 2019 (COVID-19) pandemic.MethodsIn June/July 2020, Spine Intervention Society members were queried about practice demographics, perception of COVID-19 prevalence, financial impact, and implementation of new tools and procedures when re-opening practices.ResultsOf the 2,295 members approached, 195 (8%) completed the survey. A majority (71%) reported using risk stratification tools and changing scheduling patterns. Nearly 70% performed initial assessments via telehealth and 87% for follow-up encounters. More than 80% performed symptom/temperature checks upon in-person clinic/facility entrance, and 63% screened patients via phone. Most (58%) did not test patients for COVID-19 for office visits, while 38% tested only if symptomatic. For epidural injections, intra-articular injections, and radiofrequency neurotomy procedures, 43% reported not testing patients, while 36% tested patients only if symptomatic. Most (70%) required patients to wear a mask upon entering the clinic/facility. For nonprocedure encounters, respondents used surgical masks (85%), gloves (35%), face shields/goggles (24%), N95 respirators (15%), and gowns (6%). Some (66%) discussed unique COVID-19 risks/complications and 26% provided written information. Most did not make changes to steroid dosage (67%) or peri-procedural anticoagulation management (97%). The vast majority (81%) estimated that COVID-19 will have a moderate-severe financial impact on their practice.ConclusionsCOVID-19 has dramatically affected interventional pain practices with regard to telehealth, in-clinic precautions, screening/testing protocols, and patient counseling. Practice patterns will continue to evolve as we learn more about the disease and improve methods to provide safe and effective care.

Periprocedural Anticoagulation Management of Patients receiving Warfarin in Qatar: A Prospective Cohort Study

Background: The use of anticoagulant bridging remains controversial. This study was conducted to evaluate our warfarin periprocedural management in Qatar and investigate the associated clinical outcomes with such management. Methods: A prospective cohort study was designed to describe the periprocedural clinical practice in warfarin patients in Qatar and to compare clinical safety and efficacy outcomes between anticoagulant bridging and nonbridging. Results: 103 patients were recruited. Bridging occurred in 82% of the participants. No thromboembolic events were observed, while 39.1% of patients experienced bleeding events during the study period. The incidence of overall bleeding and major bleeding were numerically higher for bridging group compared to nonbridging but did not reach statistical significance ([30.6% vs 22.2%, P = 0.478] and [12.9% vs 5.6%, P = 0.375], respectively). Conclusion: Warfarin interruption and bridging are overwhelmingly used in warfarin-treated patients in Qatar. While bridging was numerically associated with increased bleeding events, there is no statistical difference in reported clinical events between bridging and nonbridging strategies.

ANTICOAGULATION BEFORE AND AFTER CARDIOVERSION OR ABLATION. CHALLENGES, PROBLEMS AND MISTAKES

Background: Limited data exists addressing the daily use of anticoagulants for atrial fibrillation (AF) and atrial flutter (AFL) patients before and after electrical cardioversion (ECV) or catheter ablation procedures. The purpose of the study was to evaluate the appropriateness of anticoagulant therapy. Methods: We evaluated the prescribed dosage of anticoagulant therapy for 257 non-valvular AF and AFL patients scheduled for ECV or catheter ablation and the appropriateness of periprocedural anticoagulation according to European Society of Cardiology (ESC) AF Guidelines. The statistical analysis was performed using IBM SPSS Statistics software (v.26.0). Results: The majority of the patients (84%) used nonvitamin K antagonist oral anticoagulants (NOACs) for pre-procedural anticoagulation. An intervention was not performed for 12.2% of warfarin users because of insufficient hypocoagulation, while anamnesis of patients’ missed doses with a possibility of inadequate hypocoagulation occurred only in 1.9% of patients on NOACs. The odds of having insufficient pre-procedural hypocoagulation were 7.4 times higher for warfarin users compared to the NOACs group (p=0.001, OR=7.4). An incorrect NOAC dose was assigned to 22 (8.6%) patients. Rivaroxaban was the most prescribed NOAC and this group of patients had the highest percentage of incorrect dosage according to the ESC guidelines. Conclusions: Mistakes of prescribing the dosage of anticoagulant therapy are common. The majority of the patients in the study were prescribed with NOACs before and after ECV or catheter ablation procedures. Warfarin users had higher odds of the intervention not being performed and not reaching sufficient hypocoagulation prior to the procedure compared to NOACs users.

Protocol driven periprocedural anticoagulation for left atrial ablation.

A weight-based heparin dosing policy adjusted for preprocedural oral anticoagulation was implemented to reduce the likelihood of subtherapeutic dosing during left atrial catheter ablation procedures. We hypothesized that initiation of the protocol would result in a greater prevalence of therapeutic activated clotting time (ACT) values and decreased time to therapeutic ACT during left atrial ablation procedures. A departmental protocol was initiated for which subjects received intravenous unfractionated heparin (UFH) to achieve and maintain a goal of ACT >300 s. Initial bolus dose was adjusted for pre-procedure oral anticoagulation and weight as follows: 50 units/kg for those receiving warfarin, 75 units/kg for those not anticoagulated, and 120 units/kg for those on direct oral anticoagulants (DOACs). A UFH infusion was initiated at 10% of the bolus per hour. One hundred consecutive left atrial ablation procedures treated with Protocol Guided heparin dosing were compared with a retrospective consecutive cohort of Usual Care heparin dosing. When the Usual Care and Protocol Guided cohorts were compared, significant findings were limited to those on pre-procedure DOAC. The initial UFH bolus increased from 99.3 ± 24.8 to 118.2 ± 22.8 units/kg (p < .001), the proportion of therapeutic ACT on the first draw after heparin administration increased from 57.7% to 76.6% (p = .010), and the time to therapeutic ACT after UFH administration decreased from 37.8 ± 19.8 to 30.2 ± 16.4 min (p = .032). A weight-based protocol for periprocedural UFH administration resulted in a higher proportion of therapeutic ACT values and decreased the time to therapeutic ACT for those on pre-procedure DOAC.

Outcomes of uninterrupted vs interrupted Periprocedural direct oral Anticoagulants in atrial Fibrillation ablation: A meta-analysis.

BackgroundStudies indicate that uninterrupted anticoagulation (UA) is superior to interrupted anticoagulation (IA) in the periprocedural period during catheter ablation of atrial fibrillation. Still IA is followed in many centers considering the bleeding risk. This meta‐analysis compares interrupted and uninterrupted direct oral anticoagulation during catheter ablation of atrial fibrillation.MethodsA systematic search into PubMed, EMBASE, and the Cochrane databases was performed and five studies were selected that directly compared IA vs UA before ablation and reported procedural outcomes, embolic, and bleeding events. The primary outcome of the study was major adverse cerebro‐cardiovascular events.ResultsThe meta‐analysis included 840 patients with UA and 938 patients with IA. Median follow‐up was 30 days. Activated clotting time (ACT) before first heparin bolus was significantly longer with UA (P = .006), whereas mean ACT was similar between the two groups (P = .19). Total heparin dose needed was significantly higher with IA (mean, ‒1.61; 95% CI, ‒2.67 to ‒0.55; P = .003). Mean procedure time did not vary between groups (P = .81). Overall complication rates were low, with similar major adverse cerebro‐cardiovascular event (P = .40) and total bleeding (P = .55) rates between groups. Silent cerebral events (SCEs) were significantly more frequent with IA (log odds ratio, ‒0.90; 95% CI, ‒1.59 to ‒0.22; P < .01; I 2, 33%). Rates of major bleeding, minor bleeding, pericardial effusion, cardiac tamponade, and puncture complications were similar between groups.ConclusionsUA during atrial fibrillation ablation has similar bleeding event rates, procedural times, and mean ACTs as IA, with fewer SCEs.

Impact of anticoagulation strategy after left atrial appendage occlusion in patients requiring direct current cardioversion.

Current guidelines recommend adequate anticoagulation for at least 3 weeks pre- and 4 weeks post-direct current cardioversion (DCCV) to reduce thrombo-embolic risk in patients with atrial fibrillation (AF) lasting greater than 48 h. No specific recommendations exist for DCCV in patients that have undergone left atrial appendage occlusion (LAAO), many of whom are ineligible for anticoagulation. This study aims to observe the efficacy and safety of DCCV post-LAAO in everyday clinical practice. This prospective multicenter registry included DCCVs in patients post-LAAO. Imaging strategy or anticoagulation treatment around DCCV were analyzed. Complications during 30-day follow-up were registered. DCCVs performed in accordance with current guidelines for the general AF population were compared to DCCVs performed deviating from these guidelines. In 93 patients (age 65 ± 17 years, CHA2 DS2 -VASC 3.0 ± 1.3) 284 DCCVs were performed between 2010 and 2018, in 271 sinus rhythm was restored. A wide variety of imaging or anticoagulation strategies around DCCV was observed; in 128 episodes strategies deviated from current guidelines. No thrombo-embolic events were observed after any DCCV during 30-day follow-up. In 34 DCCVs trans-esophageal echocardiography (TOE) was performed before DCCV to exclude cardiac thrombi and/or (re-)verify adequate device positioning. In two patients without post-LAAO imaging before DCCV, a device rotation or embolization was observed during scheduled TOE after LAAO. DCCV in AF patients after LAAO is highly effective. No thrombo-embolic events were observed in any patient in this observational cohort, regardless of the periprocedural anticoagulation or imaging strategy. Confirmation of adequate device positioning at least once before DCCV seems recommendable.

Impact of Chronic Kidney Disease on Periprocedural Anticoagulation and Short-Term Outcomes after TAVR: A BRAVO-3 Trial Subanalysis

Impact of Chronic Kidney Disease on Periprocedural Anticoagulation and Short-Term Outcomes after TAVR: A BRAVO-3 Trial Subanalysis

Anticoagulation and bone marrow biopsy: is it safe to proceed?

ABSTRACT Background Bone marrow (BM) biopsy is the most common diagnostic procedure in hematology. Bleeding is an expected complication, and its risk is assumed to be increased in patients on anticoagulants. However, the effect of anticoagulation on BM biopsy safety is unclear and guidelines are lacking robust data in this regard. As such, physicians use their clinical judgement to guide periprocedural management of anticoagulation. objective To provide the best available evidence regarding management of anticoagulation in patients who need BM biopsy. Methods We reviewed and summarized available guidelines directing management of periprocedural anticoagulation for BM biopsy, and share our experience and practices with BM biopsy at our institution. Results The incidence of significant hemorrhage after BM biopsy is very low (0.007–1.1%). BM biopsy is classified as having a low to moderate bleeding risk. Interrupting anticoagulation is not consistently recommended. Strategies exist to minimize bleeding risk for anticoagulated patients. Patients with myeloproliferative neoplasms can develop an acquired von Willebrand syndrome which increases their risk for bleeding and therefore require extra vigilance to ensure appropriate hemostasis. Conclusion Withholding anticoagulation prior to BM biopsy is not routinely recommended. Instead, assessment and optimization of bleeding risk factors should be done on a patient by patient basis.

Periprocedural anticoagulation in the uninterrupted edoxaban vs. vitamin K antagonists for ablation of atrial fibrillation (ELIMINATE-AF) trial.

Aims This post hoc analysis of ELIMINATE-AF evaluated requirements of unfractionated heparin (UFH) and procedure-related bleeding in atrial fibrillation (AF) patients undergoing ablation with uninterrupted edoxaban or vitamin K antagonist (VKA) therapy.Methods and results Patients were randomized 2:1 to once-daily edoxaban 60 mg (or dose-reduced 30 mg) or dose-adjusted VKA (target international normalized ratio: 2.0–3.0). Uninterrupted anticoagulation was mandated for 21–28 days’ pre-ablation and 90 days’ post-ablation. During ablation, UFH administration targeted an activated clotting time (ACT) of 300–400 s. Periprocedural bleeding was differentiated between procedure-related (bleeding at puncture side, cardiac tamponade) and unrelated events. Of 614 randomized patients, 553 received study drug and underwent catheter ablation (edoxaban n = 375; VKA n = 178). The median (Q1–Q3) time from last dose to ablation procedure was 14.8 (13.3–16.5) vs. 16.5 (14.8–19.5) h (edoxaban vs. VKA group, respectively). Mean ACT (SD) ≥300 s was observed in 52% edoxaban- vs. 76% VKA-treated patients, despite a higher mean (SD) UFH dose in the edoxaban vs. VKA group [14 261 (6397) IU vs. 11 473 (4300) IU; exploratory P-value < 0.0001]. In the edoxaban group, 13 patients (3.5%) had procedure-related bleeds of whom 9 had received an UFH dose above the median (13 000 IU). In the VKA arm, 7 patients (3.9%) had procedure-related bleeds of whom 3 had received an UFH dose above the median (10 225 IU).Conclusion The rate of procedure-related major/clinically relevant non-major bleeding did not differ between the treatment arms despite higher doses of UFH used with edoxaban vs. VKA to achieve a target ACT during AF ablation.