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. 2023 Oct 4;64(4):ezad340.
doi: 10.1093/ejcts/ezad340.

Optimal management of cardiac surgery patients using direct oral anticoagulants: recommendations for clinical practice

Samuel Heuts  1   2 , Angelique Ceulemans  2   3 , Gerhardus J A J M Kuiper  2   4 , Jan U Schreiber  4 , Bernard J van Varik  5 , Renske H Olie  2   6   7 , Hugo Ten Cate  2   6   7 , Jos G Maessen  1   2 , Milan Milojevic  8 , Bart Maesen  1   2
Affiliations

Optimal management of cardiac surgery patients using direct oral anticoagulants: recommendations for clinical practice

Samuel Heuts et al. Eur J Cardiothorac Surg. .

Abstract

Objectives: Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize the current evidence and provide literature-based recommendations for the management of patients on DOACs in the perioperative phase.

Methods: A general literature review was conducted on the pharmacology of DOACs and for recommendations on the management of cardiac surgical patients on DOACs. Additionally, we performed a systematic review for studies on the use of direct DOAC reversal agents in the emergency cardiac surgical setting.

Results: When surgery is elective, the DOAC cessation strategy is relatively straightforward and should be adapted to the renal function. The same approach applies to urgent cases, but additional DOAC activity drug level monitoring tests may be useful. In emergency cases, idarucizumab can be safely administered to patients on dabigatran in any of the perioperative phases. However, andexanet alfa, which is not registered for perioperative use, should not be administered in the preoperative phase to reverse the effect of factor Xa inhibitors, as it may induce temporary heparin resistance. Finally, the administration of (activated) prothrombin complex concentrate may be considered in all patients on DOACs, and such concentrates are generally readily available.

Conclusions: DOACs offer several advantages over vitamin K antagonists, but care must be taken in patients undergoing cardiac surgery. Although elective and urgent cases can be managed relatively straightforwardly, the management of emergency cases requires particular attention.

Keywords: Antidotes; Bleeding; Cardiac surgery; Direct oral anticoagulants; Emergency.

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Figures

Figure 1:
Figure 1:
Schematic overview of the coagulation cascade and the mechanisms of action of the various anticoagulants. TF: tissue factor; VKA: vitamin K antagonist. Illustration by Barry van Varik (Pulse Medical Art).
Figure 2:
Figure 2:
Mechanisms of actions of the various indirect (A) and direct (B) DOAC reversal agents, and a visual representation of the heparin resistance hypothesis (C). AA: andexanet alfa; AT: antithrombin; DOAC: direct oral anticoagulant; PCC: prothrombin complex concentrate. Illustration by Barry van Varik (Pulse Medical Art).
Figure 3:
Figure 3:
Clinical decision pathway for perioperative management of cardiac surgery patients using DOACs. *Conventional screening tests may not be reliable. CPB: cardiopulmonary bypass; DOACs: direct oral anticoagulants; eGFR: estimated glomerular filtration rate; PCC: prothrombin complex concentrate. Illustration by Barry van Varik (Pulse Medical Art).
None
See this image and copyright information in PMC

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