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:
  1. Consider less invasive alternatives to surgery, such as PCI for ACS.
  2. Delay surgery when possible.
  3. Treat coexisting issues such as sepsis.
  4. Avoid excessive hypothermia.
  5. Exercise meticulous surgical techniques.
  6. 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.