Safety of anticoagulation with uninterrupted warfarin vs. interrupted dabigatran in patients requiring an implantable cardiac device.

BACKGROUND: The optimal strategy of peri-procedural anticoagulation in patients undergoing permanent cardiac device implantation is controversial. Our objective was to compare the major bleeding and thromboembolic complications in patients managed with uninterrupted warfarin (UW) vs. interrupted dabigatran (ID) during permanent pacemaker (PPM) or implantable cardioverter defibrillators (ICD) implantation. METHODS: A retrospective cohort study of all eligible patients from July 2011 through January 2012 was performed. UW was defined as patients who had maintained a therapeutic international normalized ratio (INR) on the day of the procedure. ID was defined as stopping dabigatran ≥12 hours prior to the procedure and then resuming after implantation. Major bleeding events included hemothorax, hemopericardium, intracranial hemorrhage, gastrointestinal bleed, epistaxis, or pocket hematoma requiring surgical intervention. Thromboembolic complications included stroke, transient ischemic attack, deep venous thrombosis, pulmonary embolism, or arterial embolism. RESULTS: Of the 133 patients (73.4±11.0 years; 91 males) in the study, 86 received UW and 47 received ID. One (1.2%) patient in the UW group sustained hemopericardium perioperatively and died. In comparison, the ID patients had no complications. As compared to the ID group, the UW group had a higher median CHADS2 score (2 vs. 3, P=0.04) and incidence of Grade 1 pocket hematoma (0% vs. 7%, P=0.09). Neither group developed any thromboembolic complications. CONCLUSIONS: Major bleeding rates were similar among UW and ID groups. Perioperative ID appears to be a safe anticoagulation strategy for patients undergoing PPM or ICD implantation.

Impact of an emergency department-initiated clinical protocol for the evaluation and treatment of atrial fibrillation.

OBJECTIVE: Published data supporting the best practice for patients with atrial fibrillation (AF) presenting to the emergency department (ED) are limited. Our objective was to evaluate the impact of an AF clinical protocol initiated in the ED with early follow-up in a specialty AF outpatient clinic. METHODS: This was a single-center prospective study of all consented patients with AF who were discharged from the ED through the AF clinical pathway and were then seen in the AF clinic. The primary endpoint was the rate of 90-day hospitalization/ED visits. Secondary endpoints included adherence to established AF anticoagulation guidelines, rate of thromboembolic events, quality of life, and patient satisfaction. RESULTS: One hundred consecutive patients were enrolled in the study. Within 90 days, 15 had ED visits and 4 were hospitalized, whereas none developed thromboembolic complications. There were significant increases in the Atrial Fibrillation Effect on QualiTy of life survey quality of life (67.3 ± 24.8 vs. 89.2 ± 15.7; P < 0.001) and patient satisfaction (66.4 ± 25.3 vs. 77.9 ± 22.8; P < 0.001) scores from baseline to 90 days. Of the 29 patients with CHADS2 score ≥2, 20 (69%) were discharged from the AF clinic with oral anticoagulation. CONCLUSIONS: We describe a novel approach to the care of patients with AF presenting to the ED. Usage of the ED-initiated AF clinical pathway with early follow-up in a protocol-driven AF clinic was associated with low readmission rates, no thromboembolic complications at 90 days, improved quality of life, and high patient satisfaction.

Cardiac perforation and lead dislodgement after implantation of a MR-conditional pacing lead: a single-center experience.

OBJECTIVE: The purpose of our study was to determine if the rate of lead-related complications was increased with the Medtronic CapSureFix MRI™ SureScan™ 5086 MRI pacing lead (5086; Medtronic Inc., Minneapolis, MN, USA) compared to the previous generation of Medtronic CapSureFix Novus™ 5076 pacing lead (5076). BACKGROUND: The 5086 lead is a newly introduced active-fixation pacemaker lead designed to be used conditionally in a magnetic resonance (MR) scanner. This lead has specific design changes compared to the previous generation of 5076 pacing leads. METHODS: This study was a retrospective case control study of 65 consecutive patients implanted with two 5086 leads compared to 92 consecutive control patients implanted with two 5076 leads over a 14-month period at a high-volume tertiary care hospital. RESULTS: Pericarditis, pericardial effusion, cardiac tamponade, or death within 30 days of implant were seen in eight patients from the 5086 cohort and two from the 5076 cohort (odds ratio 6.3, 95% confidence interval 1.3-30.8, P = 0.02). Lead dislodgement occurred in four of the 5086 patients and in none of the 5076 patients (P < 0.03). CONCLUSIONS: In a high-volume center, the incidence of pericarditis, cardiac perforation, tamponade, death, and lead dislodgement was significantly higher with the MR-conditional Medtronic 5086 lead when compared to the previous generation Medtronic 5076 lead.

Attitudes of Implanting Physicians about Cardiac Rhythm Management Devices and Their Features.

Modern cardiac rhythm management systems have become increasingly complex. The decision on which specific system to implant in a given patient often rests with the implanting physician. We conducted a multiple-choice survey to assess the opinions and preferences of cardiologists and electrophysiologists who implant and follow cardiac rhythm management systems. Reliability and battery longevity were viewed as the most important characteristics in device selection. Patient characteristics which most affected device choice were pacing indication and life expectancy. Remote technology was used in 47% of pacemaker patients, 64% of ICD patients, and 65% of CRT-D patients, with wireless (radiofrequency) remote patient monitoring associated with higher patient compliance rates (74% versus 64%, resp.). Wireless remote patient management with alerts for atrial tachyarrhythmias was felt to be important by 76% of respondents. When choosing an MR-conditional device, physicians deemed patients with prior orthopedic problems, a history of cancer, or neurological disorders to be more likely to require a future MRI. Device longevity and reliability remain the most important factors which influence device selection. Wireless remote patient monitoring with alerts is considered increasingly important when choosing a specific cardiac rhythm management system to implant.