title: Management of antithrombotic therapy in patients undergoing electrophysiological device surgery.
abstract: The aim of this review is to formulate practical recommendations for the management of antithrombotic therapy in patients undergoing cardiac implantable electronic device (CIED) surgery by providing indications for a systematic approach to the problem integrating general technical considerations with patient-specific elements based on a careful evaluation of the balance between haemorrhagic and thromboembolic risk. Hundreds of thousands patients undergo implantation or replacement of CIEDs annually in Europe, and up to 50% of these subjects receive antiplatelet agents or oral anticoagulants. The rate of CIED-related complications, mainly infective, has also significantly increased so that transvenous lead extraction procedures are, consequently, often required. Cardiac implantable electronic device surgery is peculiar and portends specific intrinsic risks of developing potentially fatal haemorrhagic complications; on the other hand, the periprocedural suspension of antithrombotic therapy in patients with high thromboembolic risk cardiac conditions may have catastrophic consequences. Accordingly, the management of the candidate to CIED surgery receiving concomitant antithrombotic therapy is a topic of great clinical relevance yet controversial and only partially, if at all, adequately addressed in evidence-based current guidelines. In spite of the fact that in many procedures it seems reasonably safe to proceed with aspirin only or without interruption of anticoagulants, restricting to selected cases the use of bridging therapy with parenteral heparins, there are lots of variables that may make the therapeutic choices challenging. The decision-making process applied in this document relies on the development of a stratification of the procedural haemorrhagic risk and of the risk deriving from the suspension of antiplatelet or anticoagulant therapy combined to generate different clinical scenarios with specific indications for optimal management of periprocedural antithrombotic therapy.
authors.affiliation: U.O.C. Cardiologia Ospedaliera, Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera Universitaria, Siena, Italy v.zaca@ao-siena.toscana.it.
authors.forename: Valerio
authors.initials: V
authors.lastname: Zacà
authors.affiliation: Dipartimento di Medicina Sperimentale e Clinica, Università di Firenze, Firenze, Italy.
authors.forename: Rossella
authors.initials: R
authors.lastname: Marcucci
authors.affiliation: Cardiologia Invasiva, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy.
authors.forename: Guido
authors.initials: G
authors.lastname: Parodi
authors.affiliation: U.O. Cardiologia, Ospedale Misericordia, Grosseto, Italy.
authors.forename: Ugo
authors.initials: U
authors.lastname: Limbruno
authors.affiliation: Dipartimento Cardiovascolare e Neurologico, Ospedale San Donato, Arezzo, Italy.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Notarstefano
authors.affiliation: Dipartimento del Cuore e dei Vasi, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Pieragnoli
authors.affiliation: Second Division of Cardiovascular Diseases, New Santa Chiara Hospital, University of Pisa, Pisa, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Di Cori
authors.affiliation: Second Division of Cardiovascular Diseases, New Santa Chiara Hospital, University of Pisa, Pisa, Italy.
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Bongiorni
authors.affiliation: Struttura Complessa di Cardiologia, Ospedale Versilia, Lido di Camaiore (LU), Italy.
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Casolo
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D058409:Cardiac Resynchronization Therapy Devices; D017147:Defibrillators, Implantable; D019468:Disease Management; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D010138:Pacemaker, Artificial; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D019106:Postoperative Hemorrhage / Q000517:prevention & control*; D019919:Prosthesis Implantation / Q000379:methods*; D013923:Thromboembolism / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors
keywords: Anticoagulation; Antiplatelet therapy; Bleeding; Coronary stent; Haemorrhage; Implantable cardioverter defibrillator; Pacemaker