Perioperative management of oral anticoagulation in patients undergoing implantation of subcutaneous implantable cardioverter-defibrillator

Muhammad R. Afzal, Divyesh Mehta, Christopher Evenson, Daniel Pinkhas, Auroa Badin, Dilesh Patel, Michael K. Essandoh, Hemant Godara, Jaret Tyler, Mahmoud Houmsse, Zhenguo Liu, Steven J. Kalbfleisch, John D. Hummel, Ralph Augostini, Raul Weiss, Emile G. Daoud, Toshimasa Okabe

Research output: Contribution to journalArticlepeer-review

9 Scopus citations


Background: The perioperative anticoagulation management during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is still evolving. Objective: The purpose of this study was to assess whether it is safe to perform S-ICD implantation with uninterrupted warfarin. Methods: This is a single-center retrospective review of patients undergoing S-ICD implantation between October 1, 2012 and June 30, 2017. One hundred thirty-seven patients underwent successful S-ICD implantation during the study period. The most common indication for implantation was primary prevention of sudden cardiac death. In 24 (17.5%) patients, warfarin was continued without any interruption (warfarin group). In 113 (82.5%) patients, no warfarin was used in the perioperative period (nonwarfarin group). The incidence of clinically significant lateral pocket hematoma was compared in the 2 groups. Results: The mean international normalized ratio was 1.83 ± 0.47 in the warfarin group and 1.09 ± 0.18 in the nonwarfarin group. A total of 8 patients developed a hematoma at the lateral pocket. No patient developed a hematoma at the parasternal pockets. Six patients (25%) in the warfarin group and 2 (1.5%) in the nonwarfarin group developed a significant lateral pocket hematoma (P =.001). The mean length of stay was longer in the warfarin group (1.23 ± 0.46 days) than in the nonwarfarin group (1.02 ± 0.18 days) (P =.0008). An international normalized ratio of >1.8 predicted the risk of hematoma. The concomitant use of dual antiplatelet therapy did not increase the risk of hematoma. None of the patients with a hematoma developed infection or required hematoma evacuation. Conclusion: Uninterrupted warfarin in the perioperative period during S-ICD implantation is associated with an increased risk of significant lateral pocket hematoma that results in prolonged hospital stay.

Original languageEnglish (US)
Pages (from-to)520-523
Number of pages4
JournalHeart Rhythm
Issue number4
StatePublished - Apr 2018
Externally publishedYes


  • Perioperative anticoagulation
  • Pocket hematoma
  • Subcutaneous implantable defibrillator
  • Sudden cardiac death
  • Uninterrupted warfarin

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)


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