An Analysis Of Bleeding Risk In Endomyocardial Biopsy - Is Oral Anticoagulant Use Safe?

• Published in: Journal of cardiac failure Vol. 30; no. 1; pp. 161 - 162
• Main Authors: Stock, James C., Carlquist, Jason, Melnyk, Megan, Ma, Jianing, Peng, Jing, Boudoulas, Konstantinos D., Kahwash, Rami
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.01.2024
• ISSN: 1071-9164; 1532-8414
• DOI: 10.1016/j.cardfail.2023.10.109

Transvenous endomyocardial biopsy (EMB) is an invasive procedure which is routinely used in the diagnosis of transplant rejection in patients with orthotopic heart transplant (OHT). EMB is generally regarded as safe, but bleeding complications have been described. It is unknown whether concomitant use of oral anticoagulants (OAC) increases the risk of bleeding in patients undergoing EMB, thus current clinical practice is variable regarding periprocedural anticoagulant continuation. The purpose of this study is to retrospectively evaluate bleeding complications amongst patients undergoing EMB while taking OAC. Patients who underwent EMB for transplant rejection surveillance at The Ohio State University Cardiac Catheterization Laboratory from November 2016 to August 2022 were studied. Patients taking OAC at the time of procedure were identified. Bleeding complications for the entire cohort were determined by reviewing the medical records for access-related hematoma or bleeding, new pericardial effusion, or red blood cell transfusion directly related to the EMB procedure without another cause of bleeding. Records of 2,196 EMB amongst 248 post-OHT patients were reviewed. Of these biopsies, 133 were excluded due to aborted procedure or multiple procedures. OAC were administered to 68 patients during the study period (14.4%), with 259 biopsies occurring in patients taking OAC. Of these patients, 142 patients were noted to be taking warfarin. The most common indications for anticoagulation were venous thromboembolism (83.5%) and atrial fibrillation (13.5%). Chart review revealed 25 bleeding events, occurring in 1.2% of all cases. Of the 25 bleeding events, 88% occurred within the first 3 months post-transplant. In the OAC group, two bleeding events were observed compared to 21 events in patients without anticoagulant use (RR 0.65, CI -0.80 - 2.10). Both bleeding events in the OAC group occurred in patients taking warfarin. Complications were also observed in two patients receiving intravenous heparin. In patients taking warfarin, INR ≥ 1.8 was associated with significantly increased bleeding risk (RR 3.82, CI 2.34-5.30) compared to patients without OAC use. Based on this retrospective data, the rate of bleeding from EMB is low, occurring in just over 1% of cases. Bleeding risk appears to be highest in the first 3 months following transplant. An INR ≥1.8 was associated with significantly increased risk of bleeding, therefore EMB should be performed only when the risk of delay outweighs bleeding risk in patients taking warfarin with INR ≥1.8.