Interatrial septal defect closure for cerebrovascular accidents: exploring the role of various anticoagulants

The role of different anticoagulants in reducing in-hospital complications in patients undergoing closure of interatrial septal defects (IASD) is unknown. In this study, we review our own experience with IASD closure data to determine if in-hospital complications and ambulation time are influenced by the use of various anticoagulants.

Fifty-five consecutive patients with a history of unexplainable stroke or transient ischemic attacks (TIA), with the exception of the presence of an IASD, were included in this study. Multiple variables were collected including age, gender, history of smoking, hypertension, diabetes, hypercholesterolemia, ejection fraction, anticoagulants used pre- and postprocedure, anticoagulants used during the closure procedure, shunt grade across the IASD pre- and postprocedure, defect size, and right-sided filling pressures. Descriptive analysis was performed on all variables including complications frequency and ambulation time, and compared between bivalirudin and indirect thrombin inhibitors.

Of 55 consecutive patients included in this study, 22 patients received bivalirudin and 33 patients received unfractionated heparin (UFH) (n = 26) or enoxaparin (n = 7). The bivalirudin patients were older (60.1 vs 50.8 years; p = 0.028), with a higher incidence of interatrial septal aneurysm (75% vs. 40.7%; p = 0.037). In-hospital complications included 1 (5%) patient with a minor bleed (groin hematoma) in the bivalirudin group, and 3 patients with minor bleed (1 GI bleed, 1 groin hematoma, and 1 transient ischemia on electrocardiogram) in the non-bivalirudin group (9.1%). No patient had a major bleed that required a transfusion or prolonged hospital stay. Ambulation time was not significantly different between the two groups (7.7 +/- 5.9 hours for bivalirudin and 6.9 +/- 5.1 hours for other anticoagulants; p = NS).

We conclude that bivalirudin is safe during IASD closure, with a statistically nonsignificant trend toward fewer minor complications than UFH and enoxaparin. No major bleeding occurred in either group. This could be due to the fact that IASD closure is performed via venous access that generally carries a low bleeding complication rate and allows safe early ambulation, irrespective of the anticoagulant utilized and despite the use of 10 and 11 Fr sheaths. Given that major differences do not appear to exist in this exploratory study between the anticoagulants studied, patent foramen ovale closure is currently being performed in our laboratory with UFH.