2.5 Schrittmacher/ automatische Defibrillator -Implantation unter oraler Antikoagulation

Eine orale Antikoagulation mit Vitamin-K-Antagonisten kann bei der Implantation eines Herzschrittmachers oder (ICD) in der Regel gefahrlos fortgesetzt werden. Die Komplikationsrate war in einer randomisierten Studie im New England Journal of Medicine („Bruise-Control“-Studie des Ottawa Heart Institute 2013; doi: 10.1056/NEJMoa1302946) sogar niedriger als bei dem von vielen Kliniken bevorzugten Bridging mit Heparin. Die Studie zeigte 3,5% klinisch relevanten Blutungen in die Implantationstasche unter der fortgesetzten oralen Antikoagulation gegenüber 16,0% im Bridging-Arm (relatives Risiko 0,19; 95-Prozent-Konfidenzintervall 0,10-0,36). Dass die Blutungsrate im Bridging-Arm höher war, war ein unerwartetes Ergebnis

Allerdings die derzeitigen US-Leitlinien empfehlen, die Vitamin-K-Antagonisten vorübergehend abzusetzen und den Implantationszeitraum durch Heparin zu überbrücken. In Abhängigkeit vom Thromboembolierisiko bevorzugen eine moderate Absenkung der INR auf Werte von circa 2,0.

Literatur

1. Guidelines on the management of valvular heart disease (version 2012). The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Authors/Task Force Members: Alec Vahanian (Chairperson) (France)*, Ottavio Alfieri (Chairperson)* (Italy), Felicita Andreotti (Italy), Manuel J. Antunes (Portugal),Gonzalo BarEuropean Heart Journal (2012) 33, 2451–2496 doi:10.1093/eurheartj/ehs109

2. Guideline on antiplatelet and anticoagulation management in cardiac surgery.Joel Dunning a, Michel Versteegh b, Alessandro Fabbri c, Alain Pavie d,Philippe Kolh e, Ulf Lockowandt f, Samer A.M. Nashef g,*on behalf of the EACTS Audit and Guidelines Committee, European Journal of Cardio-thoracic Surgery 34 (2008) 73—92

3. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Rick A. Nishimura, MD, MACC, FAHA; Catherine M. Otto, MD, FACC, FAHA; Robert O. Bonow, MD, MACC, FAHA; Blase A. Carabello, MD, FACC; John P. Erwin, MD, FACC, FAHA; Robert A. Guyton, MD, FACC; Patrick T. O’Gara, MD, FACC, FAHA; Carlos E. Ruiz, MD, PhD, FACC; Nikolaos J. Skubas, MD, FASE; Paul Sorajja, MD, FACC, FAHA; Thoralf M. Sundt, MD; James D. Thomas, MD, FASE, FACC, FAHA J. Am Coll Cardiol. 2014;63 (22):e57-e185. doi:10.1016/j.jacc.2014.02.536

Background: This guideline addresses the management of patients who are receiving anticoagulant

or antiplatelet therapy and require an elective surgery or procedure.

Methods: The methods herein follow those discussed in the Methodology for the Development of

Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and

Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical

Practice Guidelines article of this supplement.

Results: In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend

stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B).

In patients with a mechanical heart valve, atrial fi brillation, or VTE at high risk for thromboembolism,

we suggest bridging anticoagulation instead of no bridging during VKA interruption

(Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In

patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic

agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C).

In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac

surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7

to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we

recommend deferring surgery . 6 weeks after bare-metal stent placement and . 6 months after

drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C);

in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of

drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead

of stopping therapy 7 to 10 days before surgery (Grade 2C).

Conclusions: Perioperative antithrombotic management is based on risk assessment for thromboembolism

and bleeding, and recommended approaches aim to simplify patient management and

minimize adverse clinical outcomes. CHEST 2012; 141(2)(Suppl):e326S–e350S