The Canadian journal of cardiology
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In recent years the phenomenon of reverse twiddler's syndrome has been described, characterized by pulse generator manipulation resulting in lead advancement rather than retraction. We describe what we believe to be the first reported case of both classic and reverse twiddler's syndrome occurring simultaneously in a patient with a biventricular implantable cardioverter-defibrillator.
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Warfarin is effective for the prevention and treatment of thromboembolism but produces variable anticoagulant effects and requires routine monitoring of the international normalized ratio (INR) to optimize the balance between efficacy and safety. The new oral anticoagulants (NOACs) have a more predictable anticoagulant effect and were recently demonstrated to be at least as efficacious and safe as warfarin despite being administered in fixed doses without routine coagulation monitoring. Specific laboratory tests have been developed to measure the anticoagulant effect of the NOACs but are not yet widely available, and the relation between drug levels and both coagulation test results and outcomes is uncertain. ⋯ In patients with major or life-threatening bleeding and those requiring surgery, the anticoagulant effects of warfarin can be reversed using oral or intravenous vitamin K, fresh frozen plasma (FFP), and prothrombin complex concentrates (PCCs). Specific antidotes are under development for the NOACs but are not yet approved for clinical use. PCCs and recombinant factor VIIa may improve hemostasis in patients in whom bleeding develops during treatment with a NOAC, but their efficacy is unproven.
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A growing number of patients with atrial fibrillation are treated with oral anticoagulation (OAC), and a large proportion of them will require surgical or other invasive procedures. These procedures typically involve interruption of OAC with or without the use of heparin bridging; however; there has been a dramatic change in this practice during the past 3 years. The introduction of short-acting, new oral anticoagulants and the growing popularity of some low-risk procedures with continued OAC have transformed our practice. Physicians and surgeons who treat patients with atrial fibrillation must be aware of these changes and understand how to deal with the new challenges they may encounter.