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 a Mitral Bioprosthesis

The peri-procedural management of novel oral anticoagulants (NOAC) should be individualized based on patient-specific factors (age, body weight, renal function, concomitant medications, history of thromboembolic or bleeding events, and the presence of prosthetic valve) as well as procedural characteristics (bleeding risk). Less invasive procedures carry a relatively low bleeding risk and may be performed with minimal or no interruption of NOAC therapy. However, upgrading from an implantable cardioverter-defibrillator (ICD) to cardiac resynchronization therapy (CRT) is more complex than initial implantation. Therefore, the timing of the last NOAC dose before an elective procedure requires careful judgment, balancing individual risks and benefits. Herein, we present the case of an elderly patient with atrial fibrillation, grade IIIb chronic renal disease, low body weight, and a bioprosthetic mitral valve, who underwent an upgrade from an implantable cardioverter-defibrillator (ICD) to cardiac resynchronization therapy with a defibrillator (CRT-D). The patient developed bioprosthetic valve thrombosis 24 hours after edoxaban interruption without heparin bridging, which was successfully treated with ultraslow tissue plasminogen activator (tPA) therapy.