title: Risk of pocket hematoma in patients on chronic anticoagulation with warfarin undergoing electrophysiological device implantation: a comparison of different peri-operative management strategies.
abstract: OBJECTIVE
  Periprocedural management of warfarin remains challenging in patients requiring electrophysiological device surgery. For patients at high risk of thromboembolic events, guidelines recommend bridging therapy with heparin; however, this strategy is associated with a high risk of pocket hematoma. This paper systematically reviews studies appraising the risk of pocket hematoma with different perioperative anticoagulation strategies.
  
  
  METHODS
  All relevant studies identified in MEDLINE/PubMed, The Cochrane Collaboration CENTRAL, clinicaltrials.org and in bibliographies of key articles. Estimates were combined using a fixed effects model. Heterogeneity was assessed by p values of χ2 statistics and I2. Publication bias was assessed by visual examination of funnel plots and by Egger test. Fifteen studies enrolling 5911 patients met all inclusion criteria and were included in this review.
  
  
  RESULTS
  Heparin bridging compared with no heparin was associated with increased risk of pocket hematoma (OR = 4.47, 95% CI 3.21-6.23, p < 0.00001), and prolonged hospital stay (9.13 ± 1.9 days vs. 5.11 ± 1 .39 days, p < 0.00001). Warfarin continuation was not associated with increased pocket hematoma compared to warfarin discontinuation (p = 0.38), but was associated with reduced risk of pocket hematoma compared with heparin bridging (OR = 0.37, 95% CI 0.2-0.69, p = 0.002). Thromboembolic complications were reduced with heparin bridging vs. no heparin (0.50% vs.1.07%, p = 0.02), and no significant differences were reported between heparin bridging vs. warfarin continuation (p = 0.83).
  
  
  CONCLUSIONS
  Heparin bridging is associated with a higher risk of pocket hematoma and a prolonged hospital stay. Perioperative continuation of warfarin reduces the occurrence of pocket hematoma compared with heparin bridging without any significant differences in thromboembolic complications.
authors.affiliation: Cardiology Department, Luigi Sacco Hospital, Milan, Italy. vidal.essebag@mcgill.ca.
authors.forename: R
authors.initials: R
authors.lastname: Proietti
authors.forename: I
authors.initials: I
authors.lastname: Porto
authors.forename: M
authors.initials: M
authors.lastname: Levi
authors.forename: A
authors.initials: A
authors.lastname: Leo
authors.forename: V
authors.initials: V
authors.lastname: Russo
authors.forename: E
authors.initials: E
authors.lastname: Kalfon
authors.forename: G
authors.initials: G
authors.lastname: Biondi-Zoccai
authors.forename: J-F
authors.initials: JF
authors.lastname: Roux
authors.forename: D H
authors.initials: DH
authors.lastname: Birnie
authors.forename: V
authors.initials: V
authors.lastname: Essebag
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage*; D017147:Defibrillators, Implantable / Q000009:adverse effects / Q000639:trends*; D004334:Drug Administration Schedule; D006406:Hematoma / Q000139:chemically induced / Q000175:diagnosis / Q000517:prevention & control*; D006493:Heparin / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D007902:Length of Stay / Q000639:trends; D064887:Observational Studies as Topic / Q000379:methods; D010138:Pacemaker, Artificial / Q000009:adverse effects / Q000639:trends; D011300:Preoperative Care / Q000009:adverse effects / Q000379:methods*; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D012307:Risk Factors; D014859:Warfarin / Q000008:administration & dosage*
chemical_list: D000925:Anticoagulants; D014859:Warfarin; D006493:Heparin