3.1 Overall considerations:
Several documents and guidelines have been established with regards to treatment of patients on oral anticoagulants presenting with an acute bleed, or in the perioperative setting of emergency surgeries, mainly non-cardiac, where correction of the coagulopathy typically taking place before the incision is made.26,27 Cardiac surgery patients, on the other hand, present a unique challenge, especially in an emergency setting, with several issues that require consideration:
1-Does the preoperative correction of coagulopathy, with antidotes or other reversing agents, hamper subsequent heparinization and achieving therapeutic activated clotting time (ACT) needed for CPB? If so, when is the best time to administer, pre or post pump?
2-What is the risk of thromboembolism? Attention is generally directed towards avoiding bleeding, but discussion is not complete without noting the risk of thromboembolism secondary to anticoagulant interruption.14,15
3- Will postoperative anticoagulation be needed, as in cases with mechanical valves or post pump assist devices?
4-Was the underlying indication for preoperative anticoagulation addressed at the time of surgery?
Answers to the above questions may shed some light on the aggressiveness in attempting to correct an underlying coagulopathy. Postoperative bleeding will require longer delay in the resumption of the anticoagulant with the potential of increased postoperative thromboembolic risk. While achieving near normal lab values is desirable, the antidotes and prothrombin complex concentrate (PCC) may have the undesirable effect of causing thrombosis, in addition to the fact that their impact on improving outcomes is not well established.28 Alternatively, if the preoperative indication for anticoagulation was also addressed at the time of surgery, such as concomitant MAZE and left atrial appendage (LAA) clipping for preexisting AF, then the risk of future postoperative embolization may be potentially reduced such that the coagulopathy can be aggressively corrected and the need for postoperative anticoagulation avoided or at least delayed.