5. Conclusion:
Currently, there are no randomized trials or well-designed observational
studies that could direct the treatment of the difficult subset of
patients on oral anticoagulants or antiplatelet medications requiring
emergent cardiac surgery. In addition, the best metrics for complete
resolution of anticoagulant effect in not always known or available for
the newer DOACs. Therefore, at the present time only general
recommendations can be made and used as guiding principles based on
expert opinion that include the following:
- Consider less invasive alternatives to surgery, such as PCI for ACS.
- Delay surgery when possible.
- Treat coexisting issues such as sepsis.
- Avoid excessive hypothermia.
- Exercise meticulous surgical techniques.
- Correct underlying coagulopathy. Four-factor PPC can be used in
patients on VKAs or DOACs, especially if CPB needs to be instituted
quickly.
- Specific reversal agents such as idarucizumab and andexanet alfa can
be considered in cases where significant tissue dissection is
anticipated such as redo sternotomy; however, this may lead to heparin
resistance and anticoagulant rebound.
- Cytosorb adsorption may be promising for patients on antiplatelet
medications; otherwise, platelet transfusion might be necessary.
Patients on oral anticoagulants and antiplatelet medications requiring
emergency cardiac surgery present unique and formidable treatment
challenges. Benefits and risks of delaying or proceeding with surgical
intervention should be carefully weighed, through an individualized
heart-team approach. Treatment paradigms described above along with
specific institutional guidelines, algorithms and policies for urgent
reversal of anticoagulants are all helpful and should be developed to
ensure best possible outcomes.