Taking Warfarin Before Cardiac Device Surgery

Best options found for warfarin takers facing surgery
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Managing blood thinner medication before pacemaker or defibrillator surgery is a common challenge, but a new study confirms long-standing observations that uninterrupted warfarin treatment before device surgery is the best option.

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“Between 15 to 30% of patients undergoing pacemaker or defibrillator surgeries are on long-term oral anticoagulation (blood thinners),” says electrophysiologist Khaldoun Tarakji, MD, MPH. “Interruption of oral anticoagulants prior to the procedure can expose the high-risk patients to the risks of stroke and other thromboembolism events,” he says.

Why warfarin?

Anticoagulants, also known as blood thinners, protect certain patients from blood clots and possible stroke. Anyone who has a history of atrial fibrillation, deep vein thrombosis or pulmonary embolism, or has had an artificial valve, benefits from warfarin medication.

Warfarin and surgery

Surgery for patients on blood thinners requires careful evaluation. Stopping blood thinners increases the risk for clots and stroke, but too much blood thinner in a patient’s system increases the risk for uncontrolled bleeding during and after surgery.

Sometimes, patients are put on so-called bridging therapy, which substitutes heparin (given by IV or by injection in the hospital) for the warfarin prior to surgery.

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Device surgery

Closely monitored bridging therapy helps prevent clotting, but it frequently results in bruising or bleeding after device surgery. The most common problem is pocket hematoma, which is bleeding into the skin flap or pouch where the implant device is placed.

These pocket hematomas cause problems for patients, including longer hospital stays, further delays in resumption of regular medication and risk of infection.

Best options for patients

A recently conducted study published in the New England Journal of Medicine concluded that it’s safe to keep taking warfarin before cardiac device surgery. Researchers divided 681 at-risk patients into two groups. One group continued warfarin uninterrupted before surgery and the other group received bridge therapy (using intravenous heparin or low molecular weight heparin) before surgery.

Dr. Tarakji did not participate in the study. But in reviewing he says, “The investigators found that continuation of warfarin without interruption was associated with a significantly lower rate of device-pocket hematoma compared to bridging with heparin (3.5% vs. 16%).”

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He adds, “Continuation of warfarin therapy was not associated with any major perioperative bleeding events and was associated with greater patient satisfaction.”

Methods confirmed

The study’s results confirm observations made during many years of surgical procedures.

Dr. Tarakji concludes, “High-risk patients for stroke or other thromboembolic events requiring pacemaker or ICD surgery can remain on their warfarin without interruption. This will keep them protected from the risk of stroke and at the same time, this strategy, carries less risk for pocket hematoma.”

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