Introduction: Many patients requiring cardiac resynchronization therapy (CRT) are on chronic warfarin therapy. The conventional approach of holding warfarin and bridging with IV heparin or SQ enoxaparin is often associated with pocket hematoma, longer length of stay and higher health care costs. Conversely, there is concern for serious bleeding consequences with continuation of warfarin therapy if coronary sinus (CS) dissection or perforation occurs during placement of a left ventricular (LV) lead. The safety of LV lead placement with continuation of warfarin therapy remains unclear.
Methods: We retrospectively analyzed 90 consecutive patients (male 72%, mean age 73) on chronic warfarin therapy who underwent CRT device implantation (CRT-ICD 65, CRT-Pacemaker 25). The indications for anticoagulation were atrial fibrillation (72%), mechanical valve replacement (14%), pulmonary embolism (12%) and CVA (2%). Sixty-eight percent of the patients also had concurrent antiplatelet agents.
Patients were divided into three groups:
1. Peri-procedural continuation of warfarin (n=65);
2. Holding warfarin for 5 days prior to the procedure and bridging with IV heparin or SQ enoxaparin (n=10); and
3. Holding warfarin for 5 days without bridging (n=15). Endpoints assessed were clinically significant bleeding/hematoma and TIA/CVA.
Results: A LV lead was successfully implanted in 92% of patients. Pre-procedural INR was higher in Group 1 (2.5±0.38) than in Group 2 (1.24±0.14) or Group 3 (1.27±0.16). CS dissection occurred in four patients (3 in Group 1, 1 in Group 3) during the procedure without significant interference with LV lead placement. There was no incidence of hemothorax or pericardial tamponade. Clinically significant pocket hematoma occurred in two patients: one in Group 2 with IV heparin and one in Group 3 with concurrent use of both aspirin and clopidogrel. One patient in Group 3 had a TIA. Group 1 did not have any bleeding or thromboembolic event. Conclusions: CRT device implantation, while continuing warfarin therapy, appears to be safe without an increased risk of bleeding complications. This approach may simplify the peri-procedural management of anticoagulation, and could lead to improved outcomes and reduced health care costs.