Impact of peri-procedural management of direct oral anticoagulants on pocket haematoma after cardiac electronic device implantation: the StimAOD multicentre prospective study.

AIMS: The study aims to investigate the impact of direct oral anticoagulant (DOAC) management on the incidence of pocket haematoma in patients undergoing pacemaker or implantable cardioverter-defibrillator implantation. METHODS AND RESULTS: All consecutive patients receiving DOAC and undergoing cardiac electronic device implantation were included in a large multicentre prospective observational study (NCT03879473). The primary endpoint was clinically relevant haematoma within 30 days after implantation. Overall, 789 patients were enrolled [median age 80 (IQR 72-85) years old, 36.4% women, median CHA2DS2-VASc score 4 (IQR 0-8)], of which 632 (80.1%) received a pacemaker implantation. Antiplatelet therapy was combined with DOAC in 146 patients (18.5%). Direct oral anticoagulants (DOACs) were interrupted 52 (IQR 37-62) h before the procedure and resumed 31 (IQR 21-47) h later. Ninety-six percent of the patients had at least 12 h DOAC interruption before the procedure, and 78% had at least 12 h DOAC interruption after the procedure. Overall, anticoagulation was interrupted for 72 (IQR 48-96) h. Pre- or post-procedural heparin bridging was used in 8.2% and 3.9%, respectively. Timing of DOAC interruption of resumption was not associated with clinically relevant haematoma. Clinically relevant haematoma occurred in 26 patients (3.3%), and thromboembolic events occurred in 5 patients (0.6%). CONCLUSION: In this large real-life registry where most patients had DOAC interruption, clinically relevant haematoma was rare. Despite DOAC interruption and high CHA2DS2-VASc score, thromboembolic events occurred seldomly, highlighting that bleeding exceeds thromboembolic risk in this peri-procedural period. Future research is needed to identify risk factors for clinically relevant haematoma and meaningfully guide clinicians in optimizing DOAC management.

Interrelationships between interventricular electrical delays in cardiac resynchronization therapy.

INTRODUCTION: In cardiac resynchronization therapy, pacing the left ventricle (LV) at sites of prolonged electrical delay is associated with better outcomes. We sought to characterize the interrelationships between intrinsic, right-ventricular (RV)-paced, and LV-paced interventricular delays. METHODS AND RESULTS: The following electrical timings were measured at implantation for all electrodes of the LV quadripolar leads: QLV, interventricular delay in intrinsic rhythm (RVs-LVs), in RV-paced rhythm (RVp-LVs), and in LV-paced rhythm (LVp-RVs). We included 32 patients (78% men, age 72 years, LV ejection fraction 29%, left bundle branch block 84%). QLV and RVs-LVs were correlated (R2 = .72, p < .0001), as were RVs-LVs and RVp-LVs (R2 = .27, p = .002) and RVp-LVs and LVp-RVs (R2 = .60, p < .001). Direction of activation along the four LV lead electrodes was concordant between RVs-LVs and RVp-LVs in only 17 (53%) patients. The latest-activated electrodes in RVs-LVs and RVp-LVs were concordant in 26 (81%) patients, adjacent in 3 (9%) patients, and remote in 3 (9%) patients. Biventricular-paced QRS duration varied by more than 10 ms between the two electrodes in half of the patients with dissimilar latest electrodes. Among the seven echocardiographic nonresponders at 6 months, the programmed electrode was remote from the latest electrode in RVs-LVs in five patients and in RVp-LVs in three patients. CONCLUSION: Intrinsic and RV-paced interventricular electrical delays are correlated, but there is substantial heterogeneity between patients. The latest-activated electrode may be different between RVs-LVs and RVp-LVs, and this might have important implications in selecting the optimal LV vector.

Adjusted weight anticoagulation for radial approach in elective coronarography: the AWARE coronarography study.

AIMS: To evaluate the feasibility and safety of an anticoagulation adapted regimen for transradial coronary angiography. METHODS AND RESULTS: We randomly assigned 162 consecutive patients who benefited from an elective transradial approach for coronarography to receive either a standard dose of 5,000 IU heparin or 50 IU/kg with an upper limit of 5,000 IU. Patients under anti-vitamin K therapy were excluded. The TRband compression system was employed for the entire population after the procedure. Radial artery patency, the primary endpoint, was evaluated with Doppler before discharge from the hospital. Secondary endpoints were: ACT level immediately before sheath removal, compression length and bleeding complications. Both groups were well matched. ACT level is significantly lower in the adjusted anticoagulation group (231.4 min, vs. 265.6 min, p<10-4). Radial compression time was higher in the standard protocol group (235.5 min, vs. 204.5 min, p<10-5). No radial occlusion was noted, whatever the group considered. Local haematoma is less frequent in the 50 IU/kg group, with no statistical difference. CONCLUSIONS: A weight-adjusted heparin dose allows for lower ACT levels and decreases in radial compression time without increase in radial artery occlusion. The impact on bleeding complication needs further evaluation in larger series.