Original ArticlePeri-procedural Anticoagulation and the Incidence of Haematoma Formation after Permanent Pacemaker Implantation in the Elderly
Introduction
Implantation of a permanent cardiac pacemaker (PPM) is a relatively common procedure. Recently performed surveys have demonstrated that the implantation of PPMs is increasing steadily in Australia, with 590 PPM implantations per million population in 2005, a 20% increase from four years earlier [1]. Similar trends regarding PPM implantation have been reported in international studies [2].
Pocket haematoma formation is one of the most common and well-recognised complications following implantation of a PPM, with an incidence of 0.6–2.6% reported in the literature [3], [4], [5], [6], [7]. A recent audit of PPM implantation in New South Wales reported an overall complication rate of 11.9% with most complications resulting from lead displacements and pocket haematoma formation [7]. Relatively few contemporary studies have assessed PPM-related haematoma formation in detail or the clinical factors associated with this complication. One recent report indicated a high risk of haematoma formation with bridging therapy [8].
We conducted a single centre, retrospective analysis of the incidence and predictors of haematoma formation following PPM implantation, with a specific focus on the impact of anticoagulation and anti-platelet therapy.
Section snippets
Study Population
We retrospectively reviewed electronic discharge records and inpatient clinical records up to six weeks after PPM implantation of all patients (n = 518) who underwent implantation of a first PPM at Concord Repatriation General Hospital (a tertiary care facility of the Sydney South West Area Health Service) between January 2004 and December 2007 inclusive. This retrospective review was approved by the hospital Human Ethics Committee. We included both acute and elective presentations for PPM
Baseline Characteristics
A total of 518 patients received a new permanent pacemaker (PPM) at our centre between 2004 and 2007. Complete data to six weeks post-operatively was obtained in 506 patients (97.7%) with 12 patients being lost to follow-up. Our population was predominantly elderly (mean age was 76.9 ± 9.8 years) with a slight male predominance. The most common indication for pacing was high degree atrio-ventricular block (31.4%), followed by atrial fibrillation with a slow ventricular response rate (21.1%), and
Discussion
Pacemaker insertion is a common, lifesaving, procedure with a significant risk of post-operative complications. As part of the implantation process, the fascial layers within the pacemaker pocket are not sutured and remain unopposed [10]. Resultant haematoma formation results in patient discomfort, is associated with increased risk of infection and prolongs length of post-operative hospital stay. We report a clear relationship between haematoma formation and peri-operative anticoagulation,
Conclusion
Peri-operative anticoagulation is associated with a 25-fold increase in haematoma formation post-pacemaker implantation. This results in a significant increase in morbidity, length of stay and overall burden to health care costs. A bridging anticoagulation strategy accounted for all haematomas in patients anticoagulated for non-valvular atrial fibrillation. The need for bridging anticoagulation should be considered carefully, and reserved for patients at highest risk of peri-operative stroke or
Acknowledgements
We would like to acknowledge the advice and support provided by Professor J. Peat with our statistical analysis. No external financial support declared.
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Cited by (25)
Management of Perioperative Anticoagulation for Device Implantation
2018, Cardiac Electrophysiology ClinicsCitation Excerpt :Although most bleeding events associated with PPM or ICD implantation are pocket hematomas, there are other potential hemorrhagic complications to consider. Retroperitoneal bleeding, gastrointestintal bleeding, pericardial tamponade, and access site hematomas have all been described.10,13,26–28,32,33 Their frequency, however, is typically much less than 1%.
Hematoma complicating permanent pacemaker implantation: The role of periprocedural antiplatelet or anticoagulant therapy
2013, Journal of CardiologyCitation Excerpt :Thus, the authors thought that limited arm movement and periodical compression on pacemaker site during the first week of operation may reduce the rate of hematoma formation. In the literature, there are many reports about the risk of the bridging to intravenous heparin or LMWH [10,15,16]. Our findings were in contrast to these reports and LMWH bridging does not increase the rate of hematoma formation.
Peri-operative management of patients with anti-platelet or anticoagulation treatment
2012, Revista Colombiana de CardiologiaDevice surgery in the anticoagulated patient: The Goldilocks principle
2012, Heart RhythmPerioperative management of antithrombotic therapy. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
2012, ChestCitation Excerpt :Urologic surgery and procedures consisting of transurethral prostate resection, bladder resection, or tumor ablation; nephrectomy; or kidney biopsy in part due to untreated tissue damage (after prostatectomy) and endogenous urokinase release32–34 Pacemaker or implantable cardioverter-defibrillator device implantation in which separation of infraclavicular fascial layers and lack of suturing of unopposed tissues within the device pocket may predispose to hematoma development35–38 Colonic polyp resection, typically of large (ie, > 1-2 cm long) sessile polyps, in which bleeding may occur at the transected stalk following hemostatic plug release39
- 1
Contributed equally to this work.