Perioperative management of anticoagulation in patients on warfarin therapy undergoing surgery for cardiac implantable electronic devices

Many patients on chronic warfarin therapy are undergoing surgery for permanent pacemakers and implantable defibrillators, collectively known as cardiac implantable electronic device (CIED). The perioperative management of anticoagulation in these patients is a challenging clinical situation that requires balance between the risk of acute thrombosis and perioperative hemorrhage. This issue however, is inadequately addressed in the guidelines published by professional organizations. Increasing evidence suggests that temporarily interrupting anticoagulation is associated with a small but real thromboembolic risk, whereas cessation of warfarin with heparin bridging anticoagulation frequently leads to a higher incidence of pocket hematoma. Continuing warfarin with a therapeutic international normalized ratio appears to be a safe and cost-effective approach for CIED surgery in most patients with moderate to high thromboembolic risk. An algorithm is proposed for the practical management of anticoagulation and antiplatelet therapy in these patients during the perioperative period.