Managing Novel Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Device Surgery: Canadian Survey

BACKGROUND: Approximately 10% of patients who undergo surgical procedures require chronic oral anticoagulation. Physicians must balance the thromboembolic and bleeding risks to make informed decisions on whether to continue anticoagulant medication. Evidence is lacking regarding the perioperative management of novel oral anticoagulant (NOAC) agents. This survey aims to describe the management of perioperative NOAC use during device implantation by Canadian centres. METHODS: A Web-based tool was used to survey all Canadian adult pacemaker/defibrillator implant centres. The survey collected data regarding the perioperative management of NOACs in atrial fibrillation patients at high risk for thromboembolism who undergo device implantation. RESULTS: Twenty-two centres performed approximately 14,971 device implants; 1150 (8%) of these implants were in patients who were prescribed a NOAC. In 82% of centres, the NOAC is discontinued in anticipation of device implantation; 73% of these centres do not bridge with heparin. In patients with normal renal function at high risk of thromboembolic events (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack; CHADS2 ≥ 2), 72% of the centres restart the NOAC within 48 hours of the procedure. For patients with abnormal renal function (glomerular filtration rate < 80 mL/min), the timing of NOAC discontinuation is variable. Hematoma rates vary from 0 to 30%. CONCLUSIONS: Most Canadian centres perform device implantation with NOAC interruption without the use of bridging. The timing of stopping and restarting anticoagulation and incidence of bleeding complications is variable. These findings emphasize the need for randomized controlled studies to guide the optimal approach to management of NOACs during device implantation.