The patient declined prothrombin complex concentrate (PCC) because of his sedentary state and the thrombotic risk. We acknowledged his urgent need for intervention and possible surgery but opted to reverse anticoagulation first, because of his wishes and the need to maintain hemodynamic stability. The patient, a retired physician, preferred the least invasive approach and the fewest interventions. Surgery would necessitate the reversal of anticoagulation. The chief treatment options were either pericardiocentesis with or without percutaneous lead repositioning, or surgical pericardial window with or without lead extraction. The patient's hemodynamic status remained stable, and this allowed time for evaluation. The anti-Xa level calibrated for low-molecular-weight heparin (LMWH) was also elevated 23 hours after ingestion. He had normal renal function ( Table I) and a body weight of 172 lb.Īpixaban had been discontinued just before the readmission however, the patient's anti-Xa level-measured by means of an assay calibrated for unfractionated heparin (UFH)-remained elevated 12 and 23 hours after his last apixaban ingestion ( Table I). Because of his stroke risk, he was prescribed apixaban (5 mg twice/d) at discharge. One day postoperatively, the patient was discharged from the hospital after undergoing chest radiography (with normal findings), device interrogation, and incision evaluation. During the procedure, the atrial lead was repositioned.
A dual-chamber permanent pacemaker was implanted to treat the patient's brady-tachy syndrome and because ventricular pacing revealed pacemaker syndrome (hypotension that results from ventricular pacing due to the absence of the atrial kick that normally increases stroke volume during atrioventricular synchrony). An echocardiogram revealed a normal left ventricular ejection fraction (>0.60), grade II (pseudonormal) diastolic dysfunction, no significant valvular regurgitation, and normal pulmonary artery pressures. On 24-hour Holter monitoring, the predominant result was sinus rhythm. An 82-year-old man with sick sinus syndrome and paroxysmal AF presented at our catheterization laboratory from the clinic, with near-syncope and bradycardia (CHADS 2 score, 2 of 6).