Perioperative Direct Oral Anticoagulant Management During Cardiac Implantable Electronic Device Surgery: An Updated Systematic Review and Meta-analysis

Background: Patients undergoing cardiovascular implantable electronic device (CIED) implantation are often on direct oral anticoagulation (DOAC) therapy. However, the evidence on the perioperative management of DOACs in these patients is unclear. Methods: We conducted a comprehensive literature review using PubMed, Embase, and Cochrane databases through March 2024. We included studies reporting outcomes of patients on long-term DOAC therapy requiring CIED procedures – primary implants, pulse generator replacement, and device upgrades. We excluded studies exclusively reporting outcomes in patients on vitamin K antagonists. Primary outcomes were clinically significant device-pocket hematoma and thromboembolic events. Secondary outcomes included any device-pocket hematoma, all-cause mortality, major bleeding, and any bleeding. Results: A total of 1607 patients from 8 studies were included. The mean age was 73.2 years, with atrial fibrillation as the indication for DOAC therapy in the majority of patients; the mean CHA2DS2-VASc was 3.4. Of the studies included, 2 were randomized control trials (RCTs), with the remainder being observational cohort studies, of which one was propensity score matched. Our meta-analysis showed no significant difference between the 2 strategies in terms of clinically significant pocket hematoma (RR 1.70; CI 95% 0.84–3.45; p=0.14; I 2 0%), thromboembolic complications (RR 0.35; CI 95% 0.04–3.32; p=0.36; I 2 19%), and any pocket hematoma (RR 1.38; CI 95% 0.91–2.08; p=0.13; I 2 0%). Conclusion: This meta-analysis highlights a similar safety profile of uninterrupted vs. interrupted DOAC therapy in patients undergoing CIED procedures. Uninterrupted DOAC therapy is a safe and reasonable strategy in these patients. More data is needed to help guide the best approach.