5. Conclusion:
Currently, there are no randomized trials or well-designed observational studies that could direct the treatment of the difficult subset of patients on oral anticoagulants or antiplatelet medications requiring emergent cardiac surgery. 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. Four-factor PPC can be used in patients on VKAs or DOACs, especially if CPB needs to be instituted quickly.
  7. Specific reversal agents such as idarucizumab and andexanet alfa can be considered in cases where significant tissue dissection is anticipated such as redo sternotomy; however, this may lead to heparin resistance and anticoagulant rebound.
  8. Cytosorb adsorption may be promising for patients on antiplatelet medications; otherwise, platelet transfusion might be necessary.
Patients on oral anticoagulants and antiplatelet medications 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 specific institutional guidelines, algorithms and policies for urgent reversal of anticoagulants are all helpful and should be developed to ensure best possible outcomes.