1. Introduction:
“Dry going in, dry coming out” is a motto taught early on that
surgeons try to adhere to throughout their careers. This is not only in
hopes of a “quieter night” with the potential of an unstable bleeding
patient, but also for the well-documented deleterious effects of blood
transfusions.1,2 with increasing calls to restrict
utilization of blood products.3,4 Blood transfusion
and re-exploration for bleeding have been shown to increase mortality
and major morbidity after cardiac surgery,5–9 in
addition, to the increased risk seen when intervening in an emergency
setting.10
The issue is exacerbated in patients on anticoagulants, a cornerstone in
the treatment of conditions in which the risk for thromboembolism is
increased, such as atrial fibrillation (AF) and deep venous thrombosis
(DVT).11,12 Over 6-million patients are on
anticoagulants and this number is expected to rise to over 12-million in
2030, mainly due to the aging population with an increased prevalence of
AF, and to the earlier diagnosis of occult AF with use of implantable
loop recorders.11,13
The above is compounded with the increased utilization of direct oral
anticoagulants (DOACs), such as the direct thrombin inhibitor
(dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban,
edoxaban, betrixaban). DOACs have often become first-line choices in the
treatment and prevention of thromboembolism as well as stroke
prophylaxis in patients with AF.12 Randomized trials
have demonstrated the superiority of Dabigatran (RE-LY
trial)14 and Apixaban (ARISTOTLE
trial)15 over warfarin in thromboembolic stroke
prevention secondary to AF. DOACs have several other advantages over the
traditionally used vitamin-K antagonists (VKA), including rapid onset in
their action limiting the need for bridging, less drug-drug and
drug-food interactions, and easier use with reduction of blood level
monitoring.15 The American college of chest physicians
(ACCP) guidelines recommend use of DOACs for DVT and pulmonary embolism
(PE) not associated with cancer, with trials showing a decrease in major
bleeding events as compared to warfarin.16
Anticoagulant medications also include antiplatelet agents, such as
aspirin (ASA) and the P2Y12 receptor antagonists
(clopidogrel, ticagrelor and prasugrel), used for the treatment of
coronary artery disease (CAD), acute coronary syndrome (ACS) and
following percutaneous coronary interventions (PCI). Patients frequently
receive dual antiplatelet medications consisting of ASA and a
P2Y12 receptor antagonist, shown to improve survival and
reduce in-stent thrombosis.17
The above landscape has made operating on patients receiving oral
anticoagulants inevitable and an unfortunate reality. We sought to
review available literature with regards to guidelines on
anticoagulation reversals in patients receiving orals anticoagulants who
require emergency cardiac operations. Informed consent and international
review board approvals were not required and were waived for the purpose
of this study.