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    • br Practical management of perioperative anticoagulation

    2019-05-27


    Practical management of perioperative anticoagulation and antiplatelet therapy in CIED surgery By integrating the current literature and the experience from our own practice, we developed a practical algorithm recently to guide the perioperative management of anticoagulation and antiplatelet therapy in patients on warfarin therapy undergoing CIED surgery (Fig.2). Because patients may have coexisting risk factors for bleeding such as liver disease, renal dysfunction or bleeding tendencies, the actual situation may be more complex. A decision should be made based on baseline risk and the individual patient factors. Different protocols have been proposed by the others [14,38]. Update is needed when the results of the ongoing and future multicenter, randomized controlled clinical trials become available [39]. At this time, there are no data with the newer generation of anticoagulants such as dabigatran, rivaroxaban, and apixaban in the settings of CIED surgery.
    Conflict of interest
    Acknowledgement
    Introduction Cardiac resynchronization therapy (CRT) with an implantable cardioverter-defibrillator (ICD) or without an ICD (CRT-P) is recommended to reduce morbidity and mortality in patients who have New York Heart Association (NYHA) class III/IV beautiful wood failure, are symptomatic despite optimal medical therapy, and have a reduced left ventricular (LV) ejection fraction (LVEF) and electrical dyssynchrony [1–3]. The effects of CRT are reflected mainly by the degree and location of the dyssynchrony and by the successful insertion of lead into the optimal LV lead site [4,5]. No significant differences have been observed between the right ventricular apical and non-apical positions of the lead tip in a previous study [6]. In Japan, ICDs were approved by the Japanese Ministry of Health, Labor and Welfare (MHLW) in 1996. CRT-P and CRT with an ICD (CRT-D) were also approved in 2004 and 2006, respectively. The Japan Cardiac Device Treatment Registry (JCDTR) was established by the Japan Heart Rhythm Society for investigating the actual conditions of implantable devices (ICD/CRT-D) [7]. New guidelines were set forth by the Japanese Circulation Society in 2007 [8] and were then updated in 2011 [9]. The number of CRT-D implantations has markedly increased since 2006 when they were approved by the MHLW. In particular, primary prevention using CRT-D devices has dramatically increased over the last 5 years in Japan according to the JCDTR enrollment database [10], but this database has shown no significant changes in the criteria involving the QRS duration, LVEF, and NYHA class in patients with a CRT-D device over these 5 years [11]. Thus, the increase in the number of CRT-D device implantations for primary prevention did not result from an increase in the number of patients with a relatively early phase of heart failure and electrophysiologic disturbance in Japan [11].
    Methods
    Results
    Discussion
    Conclusions Mortality was associated with appropriate shocks and use of class III drugs, and appropriate shocks were associated with a younger age, male gender, and single-chamber CRT-D devices. Japanese patients with implanted CRT-D devices showed no significant differences in the prognosis irrespective of whether the criteria were fulfilled. Japanese patients with implanted CRT-D devices had a better prognosis than did those in the COMPANION trial [2].
    Conflict of interest
    Introduction It is widely accepted that treatment with cardiac resynchronization therapy (CRT) is effective for patients with advanced heart failure, and this is supported by a series of randomized, controlled clinical trials [1–6]. The underlying mechanism of this therapy is to improve the contractile movement of the heart by adjusting the interventricular (VV) and intraventricular delays. This is done by correcting electrical and mechanical dyssynchrony through an optimally timed stimulation of the right ventricle (RV) and the left ventricle (LV). The clinical benefits conferred by CRT include improvements in the quality of life, New York Heart Association functional classification, and cardiac structure and function, as well as reduction in morbidity and mortality [1–8]. Although this therapy has been proven effective in numerous clinical trials, reports show that up to one-third of patients (the so-called nonresponders) do not receive the full clinical benefit of CRT [9,10]. The causes for this nonresponsiveness of patients are still unclear; however, inadequate patient selection, suboptimal lead position, and device programming may influence the outcome. Reports show relatively equal responder rates between a Japanese cohort [11] and patients from other countries [12]. This raised the question of how daily CRT management is being practiced in Japan.