title: Meta-analysis of continuous oral anticoagulants versus heparin bridging in patients undergoing CIED surgery: reappraisal after the BRUISE study.
abstract: BACKGROUND
  Management of patients treated with oral anticoagulation (OAC) requiring a cardiovascular implantable electronic device (CIED) surgery is a challenge that requires balancing the risk of bleeding complications with the risk of thromboembolic events. Recently the approach of performing these procedures while the patient remains with a therapeutic international normalized ratio has gained interest due to several publications showing its relative safety.
  
  
  OBJECTIVE
  To evaluate the safety and effectiveness of continuous use of OAC compared with heparin bridging in the perioperative setting of CIED surgery using a meta-analysis.
  
  
  METHODS
  A systematic review of PubMed/MEDLINE, Ovid, and Elsevier databases was performed. Eligible randomized controlled trials and cohort studies were included. The outcomes studied were risk of clinically significant bleeding and of thromboembolic events. Our analysis was restricted to OAC with vitamin K antagonists.
  
  
  RESULTS
  Of 560 manuscripts initially considered relevant, seven were included in the meta-analysis, totaling 2,191 patients. Data are reported as odds ratios (ORs) with confidence interval (CI) of 95%. Maintenance of OAC was associated with a significantly lower risk of postoperative bleeding compared with heparin bridge (OR = 0.25, 95% CI 0.17-0.36, P < 0.00001). There was no difference noted in the risk of thromboembolic events between the two strategies (OR = 1.86, 95% CI 0.29-12.17, P = 0.57).
  
  
  CONCLUSIONS
  Uninterrupted use of OAC in the perioperative of CIED surgery was associated with a reduced risk of bleeding. This strategy should be considered the preferred one in patients at moderate-to-high risk of thromboembolic events.
authors.affiliation: Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, Brazil.
authors.forename: Roberto T
authors.initials: RT
authors.lastname: Sant'anna
authors.forename: Tiago L
authors.initials: TL
authors.lastname: Leiria
authors.forename: Thais
authors.initials: T
authors.lastname: Nascimento
authors.forename: João Ricardo M
authors.initials: JR
authors.lastname: Sant'anna
authors.forename: Renato A K
authors.initials: RA
authors.lastname: Kalil
authors.forename: Gustavo G
authors.initials: GG
authors.lastname: Lima
authors.forename: Atul
authors.initials: A
authors.lastname: Verma
authors.forename: Jeff S
authors.initials: JS
authors.lastname: Healey
authors.forename: David H
authors.initials: DH
authors.lastname: Birnie
authors.forename: Vidal
authors.initials: V
authors.lastname: Essebag
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage*; D015897:Comorbidity; D017147:Defibrillators, Implantable / Q000706:statistics & numerical data; D005260:Female; D006470:Hemorrhage / Q000453:epidemiology* / Q000517:prevention & control; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D015994:Incidence; D008297:Male; D010138:Pacemaker, Artificial / Q000706:statistics & numerical data; D011292:Premedication / Q000706:statistics & numerical data; D019919:Prosthesis Implantation / Q000706:statistics & numerical data*; D018570:Risk Assessment; D013923:Thromboembolism / Q000453:epidemiology* / Q000517:prevention & control*; D016896:Treatment Outcome; D014812:Vitamin K / Q000037:antagonists & inhibitors
chemical_list: D000925:Anticoagulants; D014812:Vitamin K; D006493:Heparin
keywords: CRT; defibrillation - ICD; pacing