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Perioperative anticoagulation for patients with mechanic heart valve(s) undertaking pacemaker implantation
Min Cheng1, Wei Hua, Keping Chen
1Clinical EP. Lab and Arrhythmia Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing 100037, China.
Insights
For patients with mechanical heart valves undergoing pacemaker implantation, suspending warfarin for at least 3 days before surgery reduces bleeding risks. Post-surgery, avoid low-molecular-weight heparin for 3 days and restart warfarin promptly.
Area of Science:
- Cardiology
- Cardiac Surgery
- Pharmacology
Background:
- Mechanical heart valves necessitate anticoagulation therapy.
- Pacemaker implantation is a common procedure.
- Managing anticoagulation in these patients presents a clinical challenge.
Purpose of the Study:
- To evaluate perioperative anticoagulation strategies.
- To assess complication rates in patients with mechanical heart valves undergoing pacemaker implantation.
- To determine optimal anticoagulation protocols for this patient group.
Main Methods:
- A comparative study of 109 patients with mechanical heart valves undergoing pacemaker implantation.
- Group 1: Warfarin suspended 3 days prior to surgery (n=51).
- Group 2: Warfarin suspended less than 3 days or not at all (n=58).
- Complication rates, including hemorrhage and pocket hematoma, were compared.
Main Results:
- Suspension of warfarin less than 3 days before surgery was linked to increased excessive hemorrhage (16/51 vs. 5/58, P=0.003).
- Patients with pocket hematoma were more likely to have received post-operative heparin (60% vs. 17.3%, P=0.032).
- A proposed protocol in 42 patients resulted in no pocket hematoma or embolism.
Conclusions:
- A minimum warfarin cessation of 3 days before surgery is recommended.
- Low-molecular-weight heparin should be avoided for at least 3 days post-surgery.
- A proposed protocol involves warfarin suspension (≥3 days), LMWH bridging (stopped 12h pre-op), and immediate post-op warfarin initiation.
Aims:
This study was to evaluate perioperative anticoagulation therapy in patients with mechanic heart valve(s) undergoing pacemaker implantation.
Methods And Results:
A total of 109 patients with mechanical heart valve(s) undertaking pacemaker implantation were studied. Fifty-one patients with warfarin suspended 3 days before surgery were classified into Group 1 and 58 patients with warfarin suspended <3 days or not at all into Group 2. The perioperative incidence of complications was compared. Suspension of warfarin<3 days before surgery was associated with a higher incidence of excessive haemorrhage (16/51 vs. 5/58, P=0.003). Patients with pocket haematoma were more likely to have been treated with post-operation heparin (60% vs. 17.3%, P=0.032). In 42 patients treated with proposed protocol of perioperative anticoagulation, no pocket haematoma or embolism occurred.
Conclusions:
A minimum of 3 days cessation of warfarin prior to surgery is preferred. Low-molecular-weight heparin should not be used for at least 3 days post-surgery. We propose that the protocol of perioperative anticoagulation be a suspension of warfarin not <3 days with low-molecular-weight heparin bridging stopped 12 h before surgery, and warfarin rather than low-molecular-weight heparin initiated immediately after surgery.
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