Ferretto Sonia, Mattesi Giulia, Migliore Federico, Susana Angela, De Lazzari Manuel, Iliceto Sabino, Leoni Loira, Bertaglia Emanuele
Department of Cardiac, Thoracic and Vascular Sciences, University of Padua.
Department of Cardiology, San Donà di Piave Hospital, Venice, Italy.
J Cardiovasc Med (Hagerstown). 2020 Feb;21(2):123-127. doi: 10.2459/JCM.0000000000000914.
Pocket hematoma is a common complication of cardiac implantable electronic device (CIED) procedures. the aim of the study was to research the clinical factors associated with pocket hematoma formation after CIED implantation or replacement and to identify the best perioperative antithrombotic management.
We retrospectively analyzed 500 consecutive patients who underwent to CIED implantation or replacement at our center from November 2014.
Among our population, 206 patients (41.2%) were on anticoagulant therapy at the time of the intervention: 68 (13.6%) on ongoing Warfarin; 111 (22.2%) on low-molecular-weight heparin (LMWH); and 27 (5.4%) on ongoing direct oral anticoagulants. Antiplatelet therapy was present in 262 (52.4%) patients: in particular, 50 (10%) were on dual antiplatelet therapy, 64 (12.8%) were on single antiplatelet therapy and anticoagulant therapy, whereas 12 (2.4%) were on anticoagulant with dual antiplatelet therapy.Incidence of pocket hematoma after CIEDs implantation was of 4.6%. Considering the different perioperative anticoagulant strategies, patients on LMWH presented the higher hematoma rate [11/100 patients (11.0%), P < 0.001]. At the multivariate analysis, anticoagulant with dual antiplatelet therapy (P = 0.021, OR 6.3, IC 1.3-30.8), left ventricular ejection fraction (LVEF) less than 30% (P < 0.001, OR 7.4, IC 2.7-20.4), and use of LMWH (P = 0.008, OR 3.8, IC 1.4-10.6) resulted the strongest predictors of pocket hematoma (Hosmer test = 0.899).Considering replacement procedures, incidence of pocket hematoma was of 4.4%. The incidence was higher after ICD/CRT-D replacement. The majority of pocket hematoma occurred in patients with mechanical valve prosthesis (3/4 cases, 75%, P < 0.001).
The use of LMWH and a low LVEF expose patients to a higher risk of pocket hematoma after CIED procedures. Anticoagulant with dual antiplatelet therapy and LMWH should be avoided.
囊袋血肿是心脏植入式电子设备（CIED）手术常见的并发症。本研究旨在探讨CIED植入或更换术后与囊袋血肿形成相关的临床因素，并确定最佳的围手术期抗栓治疗方案。
我们回顾性分析了2014年11月起在本中心连续接受CIED植入或更换手术的500例患者。
在我们的研究人群中，206例患者（41.2%）在干预时接受抗凝治疗：68例（13.6%）正在服用华法林；111例（22.2%）使用低分子肝素（LMWH）；27例（5.4%）正在服用直接口服抗凝剂。262例（52.4%）患者接受抗血小板治疗：具体而言，50例（10%）接受双重抗血小板治疗，64例（12.8%）接受单一抗血小板治疗并同时接受抗凝治疗，而12例（2.4%）接受抗凝治疗并同时接受双重抗血小板治疗。CIED植入术后囊袋血肿的发生率为4.6%。考虑到不同的围手术期抗凝策略，使用LMWH的患者血肿发生率更高[11/100例患者（11.0%），P<0.001]。多因素分析显示，抗凝治疗并同时接受双重抗血小板治疗（P=0.021，OR 6.3，IC范围1.3 - 30.8）、左心室射血分数（LVEF）低于30%（P<0.001，OR 7.4，IC范围2.7 - 20.4）以及使用LMWH（P=0.008，OR 3.8，IC范围1.4 - 10.6）是囊袋血肿最强的预测因素（Hosmer检验=0.899）。考虑更换手术，囊袋血肿的发生率为4.4%。ICD/CRT-D更换术后发生率更高。大多数囊袋血肿发生在机械瓣膜置换患者中（3/4例，75%，P<0.001）。
使用LMWH和低LVEF使患者在CIED手术后发生囊袋血肿的风险更高。应避免抗凝治疗并同时接受双重抗血小板治疗以及使用LMWH。
