Intrinsic bleeding risk in patients with uninterrupted oral anticoagulation undergoing cardiac implantable electronic device procedures: a pilot study

The number of cardiac implantable electronic device (CIED) proce-duresisdramaticallyincreasingworldwide[1].Upto37–46%ofpatientsrequiringdevicesurgeryareonchronicoralanticoagulation(OAC)ther-apy [2]. Perioperative anticoagulation managementrepresentsadilem-mafor physicians, particularly in the subset of patients with moderate-to-high risk of arterial thromboembolic events. Current guidelinesrecommend interruption of anticoagulation and bridging with heparin[3]. However, such strategy has been associated with increased risk ofpocket hematoma(up to 20%) [4]. More recently, observational studiesshowed that continuing warfarin for cardiac rhythm device implanta-tion is safe and is associated with lower incidence of pocket hematoma[5,6]. Noteworthy, evidence from randomized controlled studies con-firmed the efficacy and safety of uninterrupted OAC as compared withheparin bridging [7,8]. Although uninterrupted OAC is associated withreduced bleeding, a large proportion of patients remain exposed to asubstantialriskofhemorrhagiccomplications.Preventionofhematomaformation duringCIEDsurgery is animportant challenge nowadays. In-deed,pockethematomarepresentsoneofthemainriskfactorsforlocaland systemic device-related infections, leading to increased patientmorbidity and health care costs [9,10]. To further reduce bleeding riskin this setting, some experts suggest that CIED procedures should beperformed within the safest INR ranges, thus maintaining INR valuesas low as possible, according to the type of procedure [11]. However, asystematic assessment of intrinsic bleeding risk is lacking in patientswith uninterrupted OAC undergoing CIED surgery. Therefore, the iden-tification of patients at higher bleeding risk would be advantageous tooptimize perioperative management. In recent years, the bleedingscores HASBLED, ATRIA and HEMORR