Antithrombotic management in patients undergoing cardiac implantable electronic device implantation

Cardiac implantable electronic devices (CIEDs) are an established treatment option for arrhythmias, sudden cardiac death prevention, and heart failure. Approximately 1000 devices are implanted per million inhabitants in European countries each year. However, the main concern in patients with an indication for CIED implantation is frequently associated with comorbidities requiring antithrombotic medications. The invasive device implantation procedure represents a bleeding risk ranging from pocket hematoma to cardiac tamponade. On the other hand, temporary interruption of antithrombotic therapy increases the risk for thromboembolic events. Implanting CIEDs in patients on antithrombotic medications incites several clinical dilemmas of balancing thromboembolic risk against bleeding risk, as complications are associated with higher mortality rates in both aspects. The most common bleeding complication is pocket haematoma formation, which is associated with a prolonged hospital stay, higher cost, higher risk of pocket infection, and thus higher morbidity and mortality. Studies have shown that the heparin bridging strategy in patients on oral anticoagulants imposes a greater risk for pocket haematoma formation and no benefit in reducing thromboembolic events. Most procedures of CIED implantation can be performed safely with uninterrupted oral anticoagulants. Dual antiplatelet therapy increases the risk of pocket haematoma and should be avoided whenever possible.