Perioperative Direct Oral Anticoagulant Management During Cardiac
Implantable Electronic Device Surgery: An Updated Systematic Review and
Meta-analysis
Abstract
Background Patients undergoing cardiovascular implantable
electronic device (CIED) implantation are often on direct oral
anticoagulation (DOAC) therapy. However, the evidence on the
perioperative management of DOACs in these patients is unclear.
Methods We conducted a comprehensive literature review using
PubMed, Embase, and Cochrane databases through March 2024. We included
studies reporting outcomes of patients on long-term DOAC therapy
requiring CIED procedures – primary implants, pulse generator
replacement, and device upgrades. We excluded studies exclusively
reporting outcomes in patients on vitamin K antagonists. Primary
outcomes were clinically significant device-pocket hematoma and
thromboembolic events. Secondary outcomes included any device-pocket
hematoma, all-cause mortality, major bleeding, and any bleeding.
Results A total of 1607 patients from 8 studies were included.
The mean age was 73.2 years, with atrial fibrillation as the indication
for DOAC therapy in the majority of patients; the mean CHA2DS2-VASc was
3.4. Of the studies included, 2 were randomized control trials (RCTs),
with the remainder being observational cohort studies, of which one was
propensity score matched. Our meta-analysis showed no significant
difference between the 2 strategies in terms of clinically significant
pocket hematoma (RR 1.70; CI 95% 0.84–3.45; p=0.14; I
2 0%), thromboembolic complications (RR 0.35; CI
95% 0.04–3.32; p=0.36; I 2 19%),
and any pocket hematoma (RR 1.38; CI 95% 0.91–2.08;
p=0.13; I 2 0%). Conclusion This
meta-analysis highlights a similar safety profile of uninterrupted vs.
interrupted DOAC therapy in patients undergoing CIED procedures.
Uninterrupted DOAC therapy is a safe and reasonable strategy in these
patients. More data is needed to help guide the best approach.