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.