Perioperative hematoma with subcutaneous ICD implantation: Impact of anticoagulation and antiplatelet therapies. Issue 7 (22nd May 2018) - Sheldon, Seth H.
Abstract: Background: The safety of perioperative anticoagulation (AC) and antiplatelet (AP) therapy with subcutaneous implantable cardioverter‐defibrillator (S‐ICD) implantation is unknown. The purpose of this study was to identify the risk factors associated with hematoma complicating S‐ICD implantation. Methods: Records were retrospectively reviewed from 200 consecutive patients undergoing S‐ICD implantation at two academic medical centers. A hematoma was defined as a device site blood accumulation requiring surgical evacuation, extended hospital stay, or transfusion. Results: Among 200 patients undergoing S‐ICD implantation (age 49 ± 17 years, 67% men), 10 patients (5%) had a hematoma, which required evacuation in six patients (3%). Warfarin was bridged or uninterrupted in 12 and 13 patients, respectively (6% and 6.5%). Four of 12 patients with warfarin and bridging AC (33%) and two of 13 patients with uninterrupted warfarin (15%) developed a hematoma. Neither of the two patients with uninterrupted DOAC had a hematoma. No patients on interrupted AC without bridging (n = 26, 13 with warfarin, 13 with DOAC) developed a hematoma. A hematoma was also more likely with the use of clopidogrel (n = 4/10 vs 10/190, 40% vs 5.3%, P < 0.0001) in combination with aspirin in 12/14 patients. Any bridging AC (odds ratio [OR] 10.3, 1.8–60.8, P = 0.01), clopidogrel (OR 10.0, 1.7–57.7, P = 0.01), and uninterrupted warfarin without bridging (OR 11.1, 1.7–74.3, P = 0.013) were independently associated with hematoma formation. Conclusion: AC and/or AP therapy with clopidogrel appears to increase the risk for hematoma following S‐ICD implantation. Interruption of AC without bridging should be considered when it is an acceptable risk to hold AC.