5. Conclusion:
Currently, there are no randomized trials or well-designed observational
studies that could direct the treatment of this difficult subset of
patient population. In addition, the best metrics for complete
resolution of anticoagulant effect in not always known or available for
the newer DOACs. Therefore, at the present time only general
recommendations can be made and used as guiding principles based on
expert opinion that include the following:
- Consider less invasive alternatives to surgery, such as PCI for ACS.
- Delay surgery when possible.
- Treat coexisting issues such as sepsis.
- Avoid excessive hypothermia.
- Exercise meticulous surgical techniques.
- Correct underlying coagulopathy with specific anticoagulant antidotes,
reversal agents and, if necessary, blood product transfusion.
Patients on oral anticoagulants requiring emergency cardiac surgery
present unique and formidable treatment challenges. Benefits and risks
of delaying or proceeding with surgical intervention should be carefully
weighed, through an individualized heart-team approach. Treatment
paradigms described above along with intuitional specific guidelines,
algorithms and policies for urgent reversal of anticoagulants, are all
helpful and should be developed and utilized to ensure best possible
outcomes.