Pacemaker/ICD Patients: To Anticoagulate or Not To Anticoagulate?
Extrusion of thrombus from the ligated vein (especially with the cephalic vein approach)
Lead entry site
Lead-induced endothelial trauma, which causes local release of coagulation factors
Hypercoagulability induced by the surgical procedure
Atrioventricular asynchronism that causes numerous atrial contractions against closed atroventricular valves (this mechanism is even more significant in patients with 1:1 ventricular retrograde conduction)
Presence of the lead in the right ventricle
Old age in patients with pacemaker or ICD
Interventricular and intraventricular asynchronism of contraction. Venous thrombosis that occurs more than 1 year after implantation of a permanent transvenous pacemaker is usually associated with underlying venous stenosis, which may result from fibrosis of preexistent venous thrombi. The long-term residence of a permanent lead in the venous system may also act a continuing nidus for formation of a thrombus [4–6]. The presence of multiple transvenous pacemaker leads, especially if one is severed, also increases the risk of thrombosis [7, 8]. In addition, the pacing lead may produce a foreign-body type of reaction and subsequent inflammation and fibrosis along the course of the lead. In some reports on the evaluation of antiplatelet therapy and platelet aggregability in patients with pacing [9,10], Fazio et al. have shown an increase of TEEs (fatal and nonfatal stroke, fatal and nonfatal myocardial infarction, inferior limb thromboembolism) in patients treated with antiplatelet therapy compared to those not so treated (p < 0.05) ; they have shown a significant increase of β-Tromboglobulin (β-Tg) in paced patients with respect to controls. Even if their data do not conclusively demonstrate a precise causal relationship between platelet activation and increase of TEEs in patients with pacemakers or ICDs, they strongly suggest that antiplatelet drugs could represent a pathogenic treatment in these patients.
KeywordsVenous Thrombosis Subclavian Vein Venous Obstruction Cardiac Pace Pace Lead
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- 8.Fruman S et al (1987) Retained pacemaker leads. J Thorac Cardiovasc Surg 94:770–778Google Scholar
- 15.Balau J, Buysch KH, Marx E et al (1971) Thrombose der Vena subclavia nach transvenöser Schrittmacherimplantation. Radiologe 11:50–53Google Scholar
- 21.Hirsh J, Fuster V (1994) Guide to anticoagulant therapy. Part II: Oral anticoaglants. Circulation 898:1469–1480Google Scholar
- 23.Febske W, Jung W et al (1993) Multiplane transesophageal echocardiographic evaluation of transvenous defibrillation leads. Xvth Congress of the European Society of Cardiology. Eur Heart J 14:67 (abstr)Google Scholar