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Device-Pocket Hematoma after Cardiac Implantable Electronic Devices.

Up to 50% of patients who undergo cardiac implantable electronic device (CIED) surgery have an indication to antithrombotic therapy, with consequent increased risk of device-pocket hematoma and other hemorrhagic complications.1 According to a systematic review of relatively small studies, non–vitamin K antagonist oral anticoagulants (NOACs) may reduce the occurrence of hemorrhages, but evidence is limited.2 In a retrospective analysis of a US insurance claim data set, NOACs were not associated with a higher risk of hematoma at 30 days after CIED surgery.3 We prospectively investigated prevalence and determinants of device-pocket hematoma in a cohort of 871 consecutive patients who underwent CIED surgery in our center between July 2017 and July 2019. Among these, we excluded 17 patients lost to follow-up and 12 because of incomplete data. Mean age of patients was 77 years and 35% were women. Management of perioperative antithrombotic therapy was based on current guidelines.4 Single and dual antiplatelet therapy and vitamin K antagonists (VKAs) were not discontinued. We adopted an uninterrupted, or minimally interrupted, strategy in patients treated with NOACs. The last dose was given 24 hours before the procedure, and patients resumed NOACs 6 to 12 hours after the procedure. We discouraged bridging with low-molecular-weight heparin both for VKAs and NOACs because this strategy increased the risk of device-pocket hematoma as compared with uninterrupted VKAs.5 We identified 6 mutually exclusive regimens of antithrombotic therapy: (1) single antiplatelet therapy (aspirin or clopidogrel); (2) dual antiplatelet therapy (association of aspirin with clopidogrel, ticagrelor, or prasugrel; (3) VKAs; (4) NOACs (dabigatran, rivaroxaban, apixaban, or edoxaban); (5) perioperative bridging with low-molecular-weight heparin; and (6) triple antithrombotic therapy (association of one anticoagulant and 2 antiplatelet agents). An outpatient visit was scheduled 10 days after the procedure. We defined a clinically significant devicepocket hematoma as a palpable and painful swelling in the device-pocket area occurring during the 10 days after CIED surgery and associated with at least one of the following: (1) prolonged hospitalization; (2) interruption of anticoagulation therapy; and (3) reoperation. All patients gave their written informed consent, and the study was approved by the local Ethical Committee. We used STATA 15 (StataCorp, Lakeway Drive College Station, TX) for data analysis. A logistic regression model tested the univariate relationship between the demographic, clinical, and laboratory findings with the occurrence of device-pocket hematoma. Subsequently, we developed a multivariable model that included the covariates which yielded significance in the univariable models. We used the Akaike’s information criterion and the Bayesian information criterion to define the final multivariable model. This approach compares different multivariable models by rewarding the goodness of fit and penalizing the number of estimated parameters, with final selection of the model with the lowest Akaike’s information criterion and Bayesian information criterion. Device-pocket hematoma occurred in 62 patients (7.3%). As shown in the table, patients with devicepocket hematoma were more frequently affected by