The Dilemma of Edoxaban Interruption and Heparin Bridging Before Upgrading to Cardiac Resynchronization Therapy in an Older Patient with Atrial Fibrillation, Chronic Kidney Disease, and Mitral Bioprosthesis

The peri-procedural management of novel oral anticoagulants (NOAC) should be individualized based on the patient (age, body weight, renal function, medications, previous thromboembolic/bleeding event, presence of prosthetic valve) and procedural (bleeding risk) characteristics. Less invasive procedures carry a relatively low bleeding risk and may be performed under minimally- or uninterrupted NOAC therapy. However, upgrading from implantable cardioverter defibrillator (ICD) to cardiac resynchronization therapy (CRT) is more complex than the initial implantation procedure. Thus, the timing of the last NOAC intake before an elective procedure requires judgment based on the individual benefit/risk ratio. Herein, we presented the management of an elderly patient with atrial fibrillation, grade IIIb chronic renal disease, low body weight, and bioprosthetic mitral valve who underwent upgrading from ICD to CRT-D procedure, experienced a bioprosthetic valve thrombosis 24 hours after an interruption of edoxaban therapy without heparin bridging, and successfully treated with ultraslow tPA therapy.