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Cardiac resynchronization therapy device implantation in patients with therapeutic international normalized ratios
Hamid Ghanbari1, Dustin Feldman, Martin Schmidt
1Division of Cardiac Electrophysiology, Providence Hospital and Medical Centers/Wayne State University, Southfield, Michigan, USA.
Insights
Continuing warfarin therapy during cardiac resynchronization therapy device (CRT-D) implantation is safe for high-risk patients. This approach reduces pocket hematomas and shortens hospital stays compared to bridging therapy.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Many patients requiring cardiac resynchronization therapy (CRT) also need chronic anticoagulation.
- Current guidelines suggest discontinuing warfarin and using bridging therapy for CRT procedures.
- This study investigates the safety of CRT-device (CRT-D) implantation without warfarin interruption.
Purpose of the Study:
- To evaluate the safety and efficacy of continuing warfarin therapy during CRT-D implantation in patients at high risk for thromboembolic events.
- To compare outcomes between patients who continued warfarin, received bridging therapy, or had warfarin cessation.
Main Methods:
- 123 consecutive patients undergoing CRT-D implantation were enrolled.
- 49 high-risk patients received heparin, low molecular weight heparin, or warfarin therapy.
- 74 low-risk patients had warfarin cessation; all groups were monitored for hematomas, thromboembolic events, bleeding, and length of stay.
Main Results:
- The bridging therapy group had significantly higher rates of pocket hematomas (20.7%) and longer hospital stays (3.7 days) compared to control (4.1%, 1.6 days) and warfarin groups (5.0%, 2.9 days).
- Patients with prosthetic mechanical mitral valves had a higher incidence of pocket hematoma formation (20%).
- No significant difference in hematoma formation was observed between upgrade procedures and new device implantations.
Conclusions:
- Implanting CRT-Ds without interrupting warfarin therapy is a safe alternative for high-risk patients.
- This strategy reduces the risk of pocket hematomas and shortens hospital stays.
- Avoidance of bridging therapy simplifies management and improves patient outcomes.
Background:
Many patients who need cardiac resynchronization therapy (CRT) require chronic anticoagulation. Current guidelines recommend discontinuation of warfarin and the initiation of anticoagulant "bridging" therapy during these procedures. We evaluated the safety of CRT-device (CRT-D) implantation without interruption of warfarin therapy.
Methods:
A total of 123 consecutive patients requiring CRT-D therapy were enrolled, 49 identified as high risk for thromboembolic events who received either intravenous heparin, low molecular weight heparin, or warfarin therapy. The control group comprised 74 patients with low risk of thromboembolic events who required only cessation of warfarin perioperatively. Patients were evaluated at discharge and 15 and 30 days postoperatively for pocket hematomas, thromboembolic events, and bleeding. Patients' length of stay was also catalogued.
Results:
Patients in the bridging arm had a significant increase in the rate of pocket hematomas (4.1%[control] vs 5.0%[warfarin] vs 20.7%[bridging], P = 0.03) and subsequent longer length of stay (1.6 +/- 1.6 [control] vs 2.9 +/- 2.7 [warfarin] vs 3.7 +/- 3.2 [bridging], P < 0.001). Hematoma formation postoperatively was not different among patients undergoing an upgrade procedure versus those without preexisting cardiac rhythm devices (12% vs 6.2%, P = NS). Patients with a prosthetic mechanical mitral valve had a higher incidence of pocket hematoma formation (1.8% vs 20%, P = 0.03).
Conclusions:
Our findings suggest that implantation of CRT-Ds without interruption of warfarin therapy in patients at high risk of thromboembolic events is a safe alternative to routine bridging therapy. This strategy is associated with reduced risk of pocket hematomas and shorter length of hospital stay. (PACE 2010; 400-406).
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