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Case Reports
. 2018 May 16;12(1):138.
doi: 10.1186/s13256-018-1660-9.

Activated prothrombin complex concentrate to reverse the factor Xa inhibitor (apixaban) effect before emergency surgery: a case series

Nina Haagenrud Schultz  1   2   3   4 , Runar Lundblad  5 , Pål Andre Holme  6   7   8
Affiliations
Case Reports

Activated prothrombin complex concentrate to reverse the factor Xa inhibitor (apixaban) effect before emergency surgery: a case series

Nina Haagenrud Schultz et al. J Med Case Rep. .

Abstract

Background: The lack of an antidote against factor Xa inhibitors in case of major bleeding or need for urgent surgery is a concern to clinicians. Guidelines on managing major bleeding in patients under anticoagulation with a factor Xa inhibitor suggest several hemostatic agents to reverse the effect, but there is no consensus regarding the choice of drug or appropriate dose. The ability of prothrombin complex concentrate, activated prothrombin complex concentrate, and recombinant factor VIIa to reverse the effect of factor Xa inhibitors has been evaluated in animal studies, in vitro studies, and healthy volunteers, but not yet in randomized clinical studies.

Case presentation: We report a consecutive case series of patients under factor Xa inhibitor (apixaban) treatment who received activated prothrombin complex concentrate to reverse the anticoagulation effect before emergency cardiovascular surgery. Patient 1, a 63-year-old white man, was operated with replacement of the aortic valve; patient 2, a 65-year-old white man, underwent heart transplantation; patient 3, a 68-year-old white man, was operated for acute type A aortic dissection. They all received activated prothrombin complex concentrate 25 IU/kg immediately before surgery. In two of the cases, the global coagulation assay thromboelastometry (ROTEM™) was performed before and after administering activated prothrombin complex concentrate. The ROTEM™ clotting time was reduced from 1900 seconds to 740 seconds and from 1482 to 807 seconds, respectively, after administering a dose of 25 IU/kg activated prothrombin complex concentrate. The apixaban concentration before reversal was within the range considered to be the therapeutic level in all cases. No bleeding complications occurred during surgery, but one case was complicated with bleeding postoperatively. No thromboembolic complications were observed during or after surgery.

Conclusions: Activated prothrombin complex concentrate 25 IU/kg reversed the anticoagulation effect of apixaban effectively and safely before emergency cardiovascular surgery.

Keywords: Activated prothrombin complex concentrate; Apixaban; Emergency surgery; FXa inhibitors; Reversal.

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Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consents were obtained from the patients or patients’ next-of-kin for publication of this case series and any accompanying images. Copies of the written consents are available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1
Fig. 1
Thromboelastometry curves of patient 1 and patient 2. a Thromboelastometry curves before administering activated prothrombin complex concentrate 3000 IU. b Thromboelastometry curves after administering activated prothrombin complex concentrate 3000 IU. Clotting time shortened after administering activated prothrombin complex concentrate 3000 IU. aPCC activated prothrombin complex concentrate
See this image and copyright information in PMC

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