Emergency Cardiac Surgery in Patients on Oral Anticoagulants and
Emergency surgery, blood transfusion, and reoperation for bleeding have
been associated with increased operative morbidity and mortality. The
recent increased use of direct oral anticoagulants and antiplatelet
medications have made the above more challenging. In addition,
cardiopulmonary bypass (CPB) with its associated hemodilution,
fibrinolysis and platelet consumption may exacerbate the pre-existing
coagulopathy and increase the risk of bleeding. Management decisions are
typically made on a case-by-case basis. Surgery is delayed when possible
and less invasive percutaneous options should be considered if feasible.
Attention is paid to exercising meticulous techniques, avoiding
excessive hypothermia and treating coexisting issues such as sepsis.
Ensuring a dry operative field upon entry by correcting the coagulopathy
with reversal agents is offset by the concern of potentially hindering
efforts to anticoagulate the patient (heparin resistance) in preparation
for CPB, in addition to possibly increasing the risk of thromboembolism.
Proper knowledge of the anticoagulants, their reversal agents, and the
usefulness of laboratory testing are all essential. Platelet transfusion
remains mainstay for antiplatelet medications. Four-factor prothrombin
complex concentrate is considered in patients on oral anticoagulants if
CPB needs to be instituted quickly. Specific reversal agents such as
idarucizumab and andexanet alfa can be considered if significant tissue
dissection is anticipated such as redo sternotomy, but are costly and
may lead to heparin resistance and anticoagulant rebound.