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To limit the ever-increasing healthcare costs, strategies to minimize hospitalization length are warranted. In this perspective, early discharge (the same day or after 24 h) post-cardiac implantable electronic device (CIED) implantation might represent a useful strategy; nevertheless, it is imperative first to understand the timing of (potentially lethal) complications and evaluate whether this is not only an effective but also a safe clinical decision.A retrospective cohort analysis of all patients undergoing new CIED implantation from Jan 2008 to Dec 2014 was conducted. Patient demographics, comorbidities, and timing of complications post CIED implantation were evaluated, and the timing of complications was divided into intra-operative, 0-6 h (h), 6 to 24 h, and 24 h post-implant. One-year post-implant follow-up (FU) was performed in our CIED clinic.A total of 1868 patients (68% men, average age 70 years, 85% hypertension, 39% diabetes, 57% coronary artery disease, and average left ventricular ejection fraction (LVEF) 41%) received 703 (38%) pacemaker, 448 (24%) implantable cardioverter-defibrillator (ICD), 639 (34%) cardiac resynchronization therapy (CRT) devices, and 78 (4.2%) cardiac contractility modulation. A total of 199 (11%) patients experienced 214 complications. Most (75%) occurred 24 h post-implantation (with a median of 7 days). At univariate analysis, complications occurred more often in patients with a lower LVEF, on anticoagulation/antiplatelet therapy, and undergoing ICD/CRT-D implantation (p 0.05 for all).Most complications occur 24 h after first time CIED implantation. Therefore, it might not be optimal to discharge patients in ≤ 24 h, unless extensive ambulatory monitoring for complications is available.

We sought to assess the safety and effectiveness of three different devices: (1) vacuum drainage system, (2) hemostatic gelatin sponge (Stypro®), and (3) compression device (Premofix®) compared to standard of care (control) in patients undergoing cardiac implantable electronic device (CIED) implantation receiving anticoagulation and/or dual antiplatelet therapy (DAPT).We enrolled all consecutive patients admitted for first permanent CIED implantation receiving anticoagulation and/or DAPT into a prospective registry. The primary endpoint (1°EP) was a composite of hematoma grade 1 and pocket infection.We included 406 patients (median age 73 years, 71% male) of whom 103 (25%) received a vacuum drainage system, 99 (24%) received Stypro®, 103 (25%) received Premofix®, and 101 (25%) were in the control group. One hundred eighty patients (44%) were treated with anticoagulation (median INR 2.0), 176 (43%) received DAPT, and 50 (12%) both. The occurrence of the 1°EP was reduced by Stypro® (hazard ratio (HR) 0.38 (95% confidence interval (CI) 0.16-0.94) and Premofix® (HR: 0.37 (95% CI 0.15-0.90)) compared to controls (p 0.05 for both). The incidence of hematoma grade 2 or 3 was exclusively lowered by Premofix® compared to control (6% versus 15%; p 0.05) and was not affected by the type of CIED, INR (≥ 2.5 versus 2.5), body mass index (≥ 30 versus 30), or CIED implantation under anticoagulation plus DAPT. The vacuum drainage system did not affect the 1°EP or the incidence of hematoma.In patients receiving anticoagulation and/or DAPT undergoing CIED implantation, the use of Premofix® and Stypro® significantly lowered the 1°EP occurrence compared to control. Premofix® additionally lowered the frequency of pocket hematomasgrade 1.

Hintergrund Das Taschenhamatom ist eine haufige Komplikation nach Implantation von Herzrhythmusdevices (HRD, Schrittmacher, ICD, CRT) bei Patienten unter therapeutischer Antikoagulation und/oder dualer Plattchenhemmung (DAPT).

Sirs: A 73-year-old man with persistent Atrial Fibrillation (AF) and a CHA2DS2VASc Score of 3 underwent uneventful percutaneous left atrial appendage (LAA) closure (Watchman, 21 mm, Atritech, Inc., Plymouth, Minnesota) guiding fluoroscopy and transesophageal echocardiogram (TEE) in 2011 because of the inability to keep the INR within the therapeutic range (Fig. 1). TEE revealed residual flow into the LAA after implantation and also during follow-up, no flow was seen directly around the device. Warfarin was stopped 6 weeks and clopidogrel 3 months after implantation, aspirin was continued. Due to progressive arrhythmia symptoms, 15 months after implantation, successful electrical cardioversion was performed on aspirin alone after exclusion of intracardiac thrombi with TEE. The following day, the patient developed right-sided weakness and aphasia, cerebral computed tomography (CT) showed ischemia in the territory of the left medial cerebral artery. Repeat analysis of the previous TEE images revealed residual narrow flow (speed [40 cm/s) in the lateral portion of the LAA (Fig. 2). On cardiac CT, the occluder was positioned in one of the two LAA lobes and the other lobe was not occluded (Fig. 3). There was no evidence of intracardiac thrombus. The neurologic symptoms resolved quickly, and oral anticoagulation (Dabigatran, 2 9 150 mg/day) was started. Interventional LAA closure is as effective as oral anticoagulation in patients with non-valvular AF [1–6], and some case reports [7, 8] pointed out that a combined mitral valve treatment and interventional LAA closure in patients with AF and mitral valve disease is effective in reducing thromboembolic complications. In one analysis, residual peri-device flow was not associated with an increased risk of thromboembolism in PROTECT-AF [9]. However, the risk of thromboembolic complications in patients undergoing cardioversion is unknown, and there is no clear evidence that cardioversion can be performed without anticoagulant treatment after mechanical LAA occlusion. In this case, there are several important points: (1) the cause of ischemia was presumably cardiac embolic in origin (although the TEE before cardioversion did not show any thrombus). Therefore, as suggested in the guidelines, effective anticoagulant treatment is mandatory for 4 weeks after cardioversion despite closure of the LAA. The role of residual flow into the LAA after interventional LAA occlusion in increasing the risk of thromboembolic complications after cardioversion is unknown. In addition, thrombi might also evolve in the left atrium cavity due to atrial stunning after cardioversion. (2) The CT (Fig. 3) revealed a more complex 3D anatomy of the LAA, which was not seen with TEE or fluoroscopy (Fig. 1) during the procedure. Therefore, it is recommended to assess LAA anatomy with different two-dimensional views (preferably with 3D) in Electronic supplementary material The online version of this article (doi:10.1007/s00392-014-0724-0) contains supplementary material, which is available to authorized users.