Markedly increased risk of postoperative bleeding complications during perioperative bridging anticoagulation in general and visceral surgery

Abstract Background Increasing numbers of patients receiving oral anticoagulants are undergoing elective surgery. Low molecular weight heparin (LMWH) is frequently applied as bridging therapy during perioperative interruption of anticoagulation. The aim of this study was to explore the postoperative bleeding risk of patients receiving surgery under bridging anticoagulation. Methods We performed a monocentric retrospective two-arm matched cohort study. Patients that received perioperative bridging anticoagulation were compared to a matched control group with identical surgical procedure, age, and sex. Emergency and vascular operations were excluded. The primary endpoint was the incidence of major postoperative bleeding. Secondary endpoints were minor postoperative bleeding, thromboembolic events, length of stay, and in-hospital mortality. Multivariate analysis explored risk factors of major postoperative bleeding. Results A total of 263 patients in each study arm were analyzed. The patient cohort included the entire field of general and visceral surgery including a large proportion of major oncological resections. Bridging anticoagulation increased the postoperative incidence of major bleeding events (8% vs. 1%; p < 0.001) as well as minor bleeding events (14% vs. 5%; p < 0.001). Thromboembolic events were equally rare in both groups (1% vs. 2%; p = 0.45). No effect on mortality was observed (1.5% vs. 1.9%). Independent risk factors of major postoperative bleeding were full-therapeutic dose of LMWH, renal insufficiency, and the procedure-specific bleeding risk. Conclusion Perioperative bridging anticoagulation, especially full-therapeutic dose LMWH, markedly increases the risk of postoperative bleeding complications in general and visceral surgery. Surgeons should carefully consider the practice of routine bridging.

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Risk factors for thromboembolic and bleeding events in anticoagulated patients with atrial fibrillation: the prospective, multicentre observational PREvention oF thromboembolic events - European Registry in Atrial Fibrillation (PREFER in AF)

BMJ Open ◽

10.1136/bmjopen-2018-022478 ◽

2019 ◽

Vol 9 (3) ◽

pp. e022478 ◽

Cited By ~ 14

Author(s):

Miklos Rohla ◽

Thomas W Weiss ◽

Ladislav Pecen ◽

Giuseppe Patti ◽

Jolanta M Siller-Matula ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Major Bleeding ◽

Bleeding Risk ◽

Thromboembolic Events ◽

Bleeding Events ◽

Prevention Of Thromboembolic Events ◽

Major Bleeding Events ◽

Anticoagulated Patients ◽

European Registry

ObjectivesWe identified factors associated with thromboembolic and bleeding events in two contemporary cohorts of anticoagulated patients with atrial fibrillation (AF), treated with either vitamin K antagonists (VKA) or non-VKA oral anticoagulants (NOACs).DesignProspective, multicentre observational study.Setting461 centres in seven European countries.Participants5310 patients receiving a VKA (PREvention oF thromboembolic events - European Registry in Atrial Fibrillation (PREFER in AF), derivation cohort) and 3156 patients receiving a NOAC (PREFER in AF Prolongation, validation cohort) for stroke prevention in AF.Outcome measuresRisk factors for thromboembolic events (ischaemic stroke, systemic embolism) and major bleeding (gastrointestinal bleeding, intracerebral haemorrhage and other life-threatening bleeding).ResultsThe mean age of patients enrolled in the PREFER in AF registry was 72±10 years, 40% were female and the mean CHA2DS2-VASc Score was 3.5±1.7. The incidence of thromboembolic and major bleeding events was 2.34% (95% CI 1.93% to 2.74%) and 2.84% (95% CI 2.41% to 3.33%) after 1-year of follow-up, respectively.Abnormal liver function, prior stroke or transient ischaemic attack, labile international normalised ratio (INR), concomitant therapy with antiplatelet or non-steroidal anti-inflammatory drugs, heart failure and older age (≥75 years) were independently associated with both thromboembolic and major bleeding events.With the exception of unstable INR values, these risk factors were validated in patients treated with NOACs (PREFER in AF Prolongation Study, 72±9 years, 40% female, CHA2DS2-VASc 3.3±1.6). For each single point decrease on a modifiable bleeding risk scale we observed a 30% lower risk for major bleeding events (OR 0.70, 95% CI 0.64 to 0.76, p<0.01) and a 28% lower rate of thromboembolic events (OR 0.72, 95% CI 0.66 to 0.82, p<0.01).ConclusionAttending to modifiable risk factors is an important treatment target in anticoagulated AF patients to reduce thromboembolic and bleeding events. Initiation of anticoagulation in those at risk of stroke should not be prevented by elevated bleeding risk scores.

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The prognostic potential of growth differentiation factor-15 on bleeding events and patient outcome after cardiac surgery

European Heart Journal ◽

10.1093/eurheartj/ehab724.2245 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

N Kazem ◽

A Hammer ◽

L Koller ◽

F Hofer ◽

B Steinlechner ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Cardiac Surgery ◽

Major Bleeding ◽

Bleeding Risk ◽

Thromboembolic Events ◽

Bleeding Events ◽

Growth Differentiation Factor 15 ◽

All Cause Mortality

Abstract Background GDF-15 (growth/differentiation factor 15) is induced by myocardial stretch, volume overload, inflammation and oxidative stress. Its expression is tightly linked with cardiovascular events as well as the risk for major bleeding and all-cause mortality. Objective The objective of the present study was to elucidate the prognostic potential of GDF-15 in patients after cardiac surgery. Methods 504 patients undergoing elective cardiac valve and/or coronary artery bypass graft surgery were prospectively enrolled. GDF-15 levels were measured prior surgery to evaluate the impact on bleeding events, thromboembolic events and mortality. Results Preoperative GDF-15 was associated with the primary endpoint of intra- and postoperative red blood cell transfusion (for bleeding risk factors adjusted [adj] OR [odds ratio] per 1-SD [standard deviation] of 1.62 [95% CI: 1.31–2.00]; p<0.001) and postoperative atrial fibrillation (for atrial fibrillation risk factors adj. OR per 1-SD of 1.49 [95% CI: 1.22–1.81]; p<0.001). Higher concentrations of GDF-15 were observed in patients reaching the secondary endpoint of major or clinically relevant minor bleeding (for bleeding risk factors adj. OR per 1-SD of 1.70 [95% CI: 1.05–2.75]; p=0.030) during the 1stpostoperative year, but not for thromboembolic events. GDF-15 was a predictor for cardiovascular mortality (for comorbidities adj. HR [hazard ratio] per 1-SD of 1.67 [95% CI: 1.23–2.27]; p=0.001) and all-cause mortality (for comorbidities adj. HR per 1-SD of 1.55 [95% CI: 1.19–2.01]; p=0.001). A combined risk model of GDF-15 and EuroSCORE II outperformed the EuroSCORE II alone for long-term survival (c-index: 0.75 [95% CI: 0.70–0.80], p=0.046; net reclassification improvement: 33.6%, p<0.001). Conclusion Preoperative GDF-15 concentration is an independent predictor for intra- and postoperative major bleeding, major bleeding during the first year and for long-term cardiovascular or all-cause mortality after cardiac surgery. FUNDunding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Medical University of Vienna Central illustration

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The Prognostic Potential of Growth Differentiation Factor-15 on Bleeding Events and Patient Outcome after Cardiac Surgery – A prospective cohort study

Thrombosis and Haemostasis ◽

10.1055/a-1695-8327 ◽

2021 ◽

Author(s):

Niema Kazem ◽

Andreas Hammer ◽

Lorenz Koller ◽

Felix Hofer ◽

Barbara Steinlechner ◽

...

Keyword(s):

Risk Factors ◽

Cardiac Surgery ◽

Major Bleeding ◽

Bleeding Risk ◽

Thromboembolic Events ◽

Bleeding Events ◽

Growth Differentiation Factor 15 ◽

Differentiation Factor ◽

All Cause Mortality

Background: GDF-15 (growth/differentiation factor 15) is induced by myocardial stretch, volume overload, inflammation and oxidative stress. Its expression is tightly linked with cardiovascular events as well as the risk for major bleeding and all-cause mortality. The present study aimed to elucidate the prognostic potential of GDF-15 in patients after cardiac surgery. Methods: 504 patients undergoing elective cardiac valve and/or coronary artery bypass graft surgery were prospectively enrolled. GDF-15 levels were measured prior surgery to evaluate the impact on bleeding events, thromboembolic events and mortality. Results: Preoperative GDF-15 was associated with the primary endpoint of intra- and postoperative red blood cell transfusion (for bleeding risk factors adjusted [adj] OR [odds ratio] per 1-SD [standard deviation] of 1.62 [95%CI:1.31-2.00]; p<0.001). Higher concentrations of GDF-15 were observed in patients reaching the secondary endpoint of major or clinically relevant minor bleeding (for bleeding risk factors adj. OR per 1-SD of 1.70 [95%CI:1.05-2.75]; p=0.030) during the 1st postoperative year, but not for thromboembolic events. GDF-15 was a predictor for cardiovascular mortality (for comorbidities adj. HR [hazard ratio] per 1-SD of 1.67 [95%CI:1.23-2.27]; p=0.001) and all-cause mortality (for comorbidities adj. HR per 1-SD of 1.55 [95%CI:1.19-2.01]; p=0.001). A combined risk model of GDF-15 and EuroSCORE II outperformed the EuroSCORE II alone for long-term survival (c-index: 0.75 [95%CI: 0.70-0.80], p=0.046; net reclassification improvement: 33.6%, p<0.001). Conclusion: Preoperative GDF-15 concentration is an independent predictor for intra- and postoperative major bleeding, major bleeding during the first year and for long-term cardiovascular or all-cause mortality after cardiac surgery.

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Increased Postoperative Bleeding Risk among Patients with Local Flap Surgery under Continued Clopidogrel Therapy

BioMed Research International ◽

10.1155/2015/120903 ◽

2015 ◽

Vol 2015 ◽

pp. 1-5 ◽

Cited By ~ 7

Author(s):

Wolfgang Eichhorn ◽

Martina Haase ◽

Lan Kluwe ◽

Jürgen Zeuch ◽

Ralf Smeets ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Univariate Analysis ◽

Postoperative Bleeding ◽

Tumor Resection ◽

Bleeding Risk ◽

Skin Tumor ◽

Bleeding Complications ◽

Skin Grafts ◽

Clopidogrel Therapy ◽

Study Population

Purpose. The purpose of the study was to evaluate the influence of a continued antiplatelet therapy with clopidogrel on postoperative bleeding risk in patients undergoing skin tumor resection and reconstruction with local flaps or skin grafts under outpatient conditions.Patients and Methods. The authors designed and implemented a retrospective clinical cohort study at the General Hospital Balingen. The primary endpoint was the bleeding ratio in patients with clopidogrel treatment in comparison to patients without any anticoagulant or antiplatelet therapy. Wound healing was evaluated on days 1, 3, 5, 7, 10, and 14.Results. 650 procedures were performed, 123 of them under continued clopidogrel therapy. There were significantly more postoperative bleeding complications among patients with continued antiplatelet therapy. Regarding the whole study population, malignant lesions, a larger defect size, and skin grafts were accompanied by a higher rate of bleeding incidents. However, there were no significant findings in the univariate analysis of the clopidogrel group. All bleeding incidents were easily manageable.Conclusion. Despite an increased bleeding ratio among patients under continued clopidogrel therapy, the performance of simple surgical procedures can be recommended. However, cautious preparation and careful hemostasis are indispensable.

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Bleeding, thrombosis and transfusion in patients on ECMO: A retrospective study in a tertiary center in Hong Kong

The International Journal of Artificial Organs ◽

10.1177/0391398820965584 ◽

2020 ◽

pp. 039139882096558

Author(s):

Ka Man Fong ◽

Shek Yin Au ◽

George Wing Yiu Ng ◽

Anne Kit Hung Leung

Keyword(s):

Risk Factors ◽

Bloodstream Infection ◽

Primary Outcome ◽

Significant Risk ◽

Tertiary Hospital ◽

Chinese Patients ◽

Bleeding Complications ◽

Bleeding Events ◽

Tertiary Center ◽

Independent Risk Factors

Purpose: Use of anticoagulation in patients on ECMO, especially in Chinese, has always been difficult. This study aimed to review the incidence of bleeding, thrombosis, and transfusion requirement in Chinese ECMO patients and to identify risk factors for bleeding complications. Materials and Methods: This was a retrospective observational study of a tertiary hospital from 2010 to 2018. Patients aged ⩾18 years who received ECMO were included. The primary outcome was incidence of bleeding. Secondary outcomes included ICU mortality, hospital mortality, and length of the ICU and hospital stay. Results: Of the 130 patients, 55(42.3%) had at least one bleeding events and thrombosis occurred in 37(28.5%). A lower fibrinogen level (adjusted OR 0.56 (0.36–0.86), p = 0.009), bloodstream infection (adjusted OR 2.76 (1.01–7.53), p = 0.047) and longer duration on ECMO (adjusted OR 1.14 (1.02–1.27), p = 0.018) were independently associated with occurrence of bleeding. APTT (adjusted OR 0.99 (0.97–1.01), p = 0.370) and platelet count (adjusted OR 1.00 (0.98–1.01), p = 0.632) were not statistically significant risk factors for bleeding events. Conclusions: Bleeding and thrombosis were common complications in Chinese patients receiving ECMO. Hypofibrinogenemia and bloodstream infection, but not APTT nor platelet counts, were independent risk factors for bleeding events.

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Acute Kidney Disease Increases the Risk of Post-Kidney Biopsy Bleeding Complications

Kidney & Blood Pressure Research ◽

10.1159/000509443 ◽

2020 ◽

Vol 45 (6) ◽

pp. 873-882

Author(s):

Jing Xu ◽

Xiaojing Wu ◽

Yaowen Xu ◽

Hong Ren ◽

Weiming Wang ◽

...

Keyword(s):

Risk Factors ◽

Kidney Disease ◽

Kidney Biopsy ◽

Clinical Laboratory ◽

Kidney Diseases ◽

Bleeding Risk ◽

Bleeding Complications ◽

Pathological Findings ◽

Macroscopic Hematuria ◽

Acute Kidney Disease

Introduction: Kidney biopsy, providing the insightful information for most kidney diseases, is an invasive diagnostic tool with certain risks ranging from the least severe macroscopic hematuria to the most severe life-threatening bleeding necessitating renal artery embolization. We aimed to compare the postbiopsy bleeding complications between 2 common methods and to further explore the risk factors of bleeding complications in patients using the negative pressure suction puncture (NPS) method. Methods: We retrospectively collected the data from percutaneous native kidney biopsies in 2016. The clinical, laboratory tests, pathological findings, and the occurrence of bleeding complications following kidney biopsy were analyzed. The kidney biopsy was performed in our center by experienced nephrologists with 2 different methods, namely, NPS method and real-time ultrasound-guided needle (RTU) method. We compared rates of complications between 2 methods and evaluated univariate and multivariate association of risk factors with bleeding complications in the NPS group. Results: 626 kidney biopsies were performed between January 2016 and December 2016. There were 83.2% (521/626) participants in the NPS group and 16.8% (105/626) in the RTU group. There were more participants in the RTU group needing >1 needle pass during biopsy than those in the NPS group (61.0 vs. 14.7%, p < 0.001). Acute kidney disease (AKD) occurred before the procedure of kidney biopsy accounted for 13.8% (72/521) in the NPS group and 1.9% (2/105) in the RTU group. The renal pathological findings revealed higher number of glomeruli in the NPS group than in the RTU group (26.8 ± 13.0 vs. 17.2 ± 8.6, p < 0.001). The incidence of bleeding complications in the NPS group was lower than that in the RTU group (9.2 vs. 21.9%, p < 0.01). Logistic multivariate regression showed that AKD was independently associated with bleeding complications after kidney biopsy in the NPS group. Conclusion: Regarding the bleeding risk, there was noninferiority of NPS over RTU. AKD contributes to higher risks of bleeding complications after kidney biopsy.

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Bleeding complications after systematic switch of routine thromboprophylaxis for major orthopaedic surgery

Thrombosis and Haemostasis ◽

10.1160/th08-01-0019 ◽

2008 ◽

Vol 99 (06) ◽

pp. 1049-1052 ◽

Cited By ~ 6

Author(s):

Urs Kistler ◽

Inès Quervain ◽

Urs Munzinger ◽

Nils Kucher

Keyword(s):

Postoperative Bleeding ◽

Bleeding Complications ◽

Thromboembolic Events ◽

Venous Thromboembolic Events ◽

Major Orthopedic Surgery ◽

Venous Thromboembolic ◽

Major Orthopaedic Surgery ◽

Orthopedic Patients ◽

Second Period ◽

Observation Period

SummaryThe rate of bleeding complications after major orthopedic surgery approximates 2%. It is unclear whether a systematic switch of routine thromboprophylaxis has an impact on the rate of postoperative bleeding complications. We analyzed prospectively recorded postoperative bleeding complications and symptomatic venous thromboembolic events in 8,176 consecutive orthopedic patients at the Schulthess Clinic Zurich during a systematic switch of thromboprophylaxis from nadroparin to enoxaparin in the year 2004. Overall, 3,893 patients received nadroparin in the first nine-month observation period before the switch and 4,283 patients received enoxaparin in the second nine-month observation period after the switch. Overall, 96 (2.5%) patients in the first period and 70 (1.6%) patients in the second period suffered a postoperative bleeding complication requiring surgical revision, puncture, or transfusion (p<0.01). Five objectively confirmed symptomatic venous thromboembolic events during hospitalization in the first period and three events in the second period were recorded. In conclusion, the switch of thromboprophylaxis in a large orthopedic clinic did not cause an increase of postoperative bleeding complications and therefore was accompanied by high patient safety.

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Percutaneous Coronary Intervention–Related Bleeding Risk Factors in Current Practice

Annals of Pharmacotherapy ◽

10.1345/aph.1g057 ◽

2005 ◽

Vol 39 (10) ◽

pp. 1627-1633 ◽

Cited By ~ 7

Author(s):

A Scott Mathis ◽

James J Gugger

Keyword(s):

Risk Factors ◽

Percutaneous Coronary Intervention ◽

Renal Function ◽

Length Of Stay ◽

Bleeding Risk ◽

Coronary Intervention ◽

Bleeding Complications ◽

Minor Bleeding ◽

Prolonged Length ◽

Percutaneous Coronary

BACKGROUND: Bleeding is a common and costly complication of percutaneous coronary intervention (PCI). Little is known about the risk factors for bleeding complications. Objective: To report our PCI-related observations from a single institution and use the information to establish risk factors for short-term bleeding complications, with special focus on examining the importance of renal function. METHODS: A retrospective record review was conducted of the admission of 300 patients grouped according to antithrombotic regimen: unfractionated heparin alone (n = 187), bivalirudin (n = 26), and glycoprotein IIb/IIIa antagonist plus heparin (n = 103). Bleeding and ischemic outcomes were tracked. A model was constructed to predict independent bleeding risk factors. RESULTS: Treatment groups differed significantly regarding any bleeding (p = 0.001), minor bleeding (p < 0.001), and length of stay (p = 0.01). Multivariate predictors of any bleeding included antithrombotic regimen, creatinine clearance (Clcr) <30 mL/min, and hypertension. Any bleeding was associated with prolonged length of stay. Major bleeding was predicted by Clcr <30 mL/min and was associated with prolonged length of stay and death. Minor bleeding was predicted only by choice of antithrombotic regimen. CONCLUSIONS: The major influences on bleeding risk appeared to be Clcr <30 mL/min and choice of antithrombotic regimen. It is important to note that other markers of renal function, including serum creatinine value and serum creatinine at a cutoff level of 1.5 mg/dL, did not predict bleeding events.

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Association between Renal Function and Bleeding Risk for Dabigatran after Switching from Warfarin

American Journal of Nephrology ◽

10.1159/000446848 ◽

2016 ◽

Vol 44 (1) ◽

pp. 11-18 ◽

Cited By ~ 3

Author(s):

Roberto S. Kalil ◽

Peter J. Kaboli ◽

Xin Liu ◽

Mary Vaughan-Sarrazin

Keyword(s):

Renal Function ◽

Healthcare Providers ◽

Bleeding Risk ◽

Bleeding Complications ◽

Close Monitoring ◽

Gi Bleeding ◽

Bleeding Events ◽

National Patient ◽

Study Population ◽

The Impact

Background: There is a higher risk of gastrointestinal (GI) bleeding in patients treated with dabigatran versus warfarin. We analyzed the impact of renal function on the relative risk of bleeding in patients converted to dabigatran. Methods: Patients aged ≥65 years who received anticoagulation with warfarin for a minimum of 6 months and subsequently converted to dabigatran or remained on warfarin were studied. Data sources included VA National Patient Care, and VA Decision Support System National Pharmacy and Laboratory. Each patient who converted to dabigatran 150 mg twice daily was matched by propensity score with 2 patients on warfarin who did not convert. Outcomes included rates of hospital admission for GI or other major bleeding and mortality, stratified by estimated glomerular filtration rate (eGFR). Results: Study population included 864 patients who converted and 1,710 patients who did not convert to dabigatran. In patients with eGFR 50-80 ml/min/1.73 m², the hazard of GI bleeding in patients who initiated dabigatran was nearly 3 times higher, (4.1 vs. 1.3 per 100 patient years; hazards ratio 2.94; 95% CI 1.24-7.02; p = 0.015), compared to patients who remained on warfarin. There were relatively few patients with eGFR <50 or >80 ml/min/1.73 m2, and relatively few bleeding events outside the GI tract. Conclusions: Prescribing healthcare providers should exercise caution and close monitoring for bleeding complications when converting from warfarin to dabigatran, even in patients with renal function in the range considered safe for dabigatran use as per current recommendations.

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Non-vitamin K antagonist oral anticoagulants in adult congenital heart disease: a single-center study

European Heart Journal ◽

10.1093/eurheartj/ehab724.1867 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

P Garcia Bras ◽

T Mano ◽

T Rito ◽

A Castelo ◽

V Ferreira ◽

...

Keyword(s):

Congenital Heart Disease ◽

Heart Disease ◽

Congenital Heart ◽

Septal Defect ◽

Oral Anticoagulants ◽

Fontan Circulation ◽

Bleeding Complications ◽

Atrial Arrhythmias ◽

Thromboembolic Events ◽

Bleeding Events

Abstract Introduction Adults with congenital heart disease (ACHD) are at an increased risk for thromboembolic events and atrial arrhythmias are common in this population. Non-vitamin K anatagonist oral anticoagulants (NOACs) prescription is increasing, however data on efficacy and safety in ACHD is unclear, particularly in patients (P) with complex CHD. The aim of the study was to review the use of NOACs in various types of ACHD and assess its safety and efficacy. Methods Evaluation of consecutive ACHD P started on NOAC therapy from 2014 to 2020. P were followed-up for bleeding or thromboembolic events and mortality. CHA2DS2-VASc and HASBLED scores were calculated and risk factors for bleeding were identified. Results 93 ACHD P were included, mean age 52±15 years, 58% female, 44% with complex CHD (3.2% with Fontan circulation), with diagnosis of: 22.2% atrial septal defect, 20% tetralogy of Fallot, 11.1% transposition of the great arteries, 10% Ebstein's anomaly, 8.9% ventricular septal defect, 7.8% pulmonary stenosis, 5.6% ductus arteriosus, 4.4% AV septal defect, 3.4% univentricular heart, 3.4% coarctation of aorta, 2.2% supra-aortic stenosis and 1% with Uhl disease. Most P were anticoagulated with rivaroxaban (43%), followed by edoxaban (24%), apixaban (20%), and dabigatran (13%). The indications for anticoagulation were: atrial arrhythmias (81%), pulmonary embolism (PE) (6.3%), atrial thrombi (4.3%), thromboprophylaxis in Fontan circulation (3.2%), deep vein thrombosis (3.2%) and stroke (2%). 66% of P had a CHA2DS2-VASc score ≥2 and 82% HASBLED score ≤2. In a mean follow-up of 41±21 months (400.4 patient-years), there were embolic events in 2P (1 splenic infarction and 1 PE) albeit both were in the context of oral anticoagulation interruption. The cardiovascular mortality was 2% and allcause mortality 5%, however with no relation to thrombosis or bleeding events. 6 P (6.5%) suffered a minor and 3 P (3.2%) suffered a major bleeding, a median time of 12 (IQR 15) months after starting NOAC therapy. The annual risk for bleeding was 2.2%/patient/year. P with bleeding events showed no significant difference regarding age (55±16 vs 52±15 years, p=0.587), gender (13% female vs 5.1% male, p=0.295) or CHD type (p=0.582). 8.6% of P required dose reduction, mostly for bleeding (3.2%) or renal impairment (2.2%). Renal disease was a strong risk factor for major bleeding (HR 14.6 [95% CI 1.23–73.6], p=0.033 and multivariate analysis showed that an increased HASBLED score was an independent predictor of minor (adjusted HR 3.44 [95% CI 1.13–10.52], p=0.030) and major (adjusted HR 5.29 [95% CI 1.14–24.45], p=0.033) bleeding complications. Conclusion Anticoagulation with NOACs is a safe and effective option for selected ACHD P, although bleeding complications were not negligible, particularly in P with renal disease. Larger scale research studies are required, especially regarding complex CHD such as P with Fontan circulation. FUNDunding Acknowledgement Type of funding sources: None.

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