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. 2024 Jan 29;10(1):6.
doi: 10.1186/s40981-024-00690-8.

Andexanet alpha-induced heparin resistance treated by nafamostat mesylate in a patient undergoing total aortic arch repair for Stanford type A acute aortic dissection: a case report

Yasuhito Suzuki  1 , Mutsuhito Kikura  2 , Shingo Kawashima  3 , Tetsuro Kimura  3 , Yoshiki Nakajima  3
Affiliations

Andexanet alpha-induced heparin resistance treated by nafamostat mesylate in a patient undergoing total aortic arch repair for Stanford type A acute aortic dissection: a case report

Yasuhito Suzuki et al. JA Clin Rep. .

Abstract

Background: Andexanet alfa, an anti-Xa inhibitor antagonist, induces heparin resistance. Here, we report a case of successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesylate.

Case presentation: An 84-year-old female, with Stanford type A acute aortic dissection, underwent an emergency surgery for total aortic arch replacement. Andexanet alfa 400 mg was administered preoperatively to antagonize edoxaban, an oral Xa inhibitor. Heparin 300 IU/kg was administered before cardiopulmonary bypass, and the activated clotting time (ACT) was 291 s. The ACT was 361 s after another administration of heparin 200 IU/kg. According to our routine therapy for heparin resistance, an initial dose of nafamostat mesylate 10 mg was administered intravenously, followed by a continuous infusion of 20-30 mg/h. The ACT was prolonged to 500 s, and cardiopulmonary bypass was successfully established thereafter.

Conclusions: This case report presents the successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesilate. This report presents the successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesilate.

Keywords: Andexanet alpha; Antithrombin; Cardiovascular surgery; Direct oral anticoagulants; Heparin resistance; Nafamostat mesylate; Oral Xa inhibitor.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
The chronological changes in activated clotting time (ACT) during the perioperative period. Andexanet alfa 400 mg was administered preoperatively. Heparin resistance was observed after administration of 500 IU/kg heparin before cardiopulmonary bypass. ACT was prolonged to 500 s after the administration of an initial dose of nafamostat mesilate 10 mg, followed by a continuous infusion of 20–30 mg/h. Cardiopulmonary bypass was successfully established thereafter ACT, activated clotting time
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