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.