Allegheny General Hospital, Pittsburgh, PA, USA.
Ann Pharmacother. 2012 Sep;46(9):e21. doi: 10.1345/aph.1R081. Epub 2012 Aug 7.
To describe a case in which hemodialysis was performed before cardiac transplantation in an attempt to reverse the effects of dabigatran and reduce the risk of bleeding associated with surgery.
A 59-year-old female with heart failure and atrial fibrillation was admitted for orthotropic heart transplant. She had been stable at home with continuous milrinone therapy 0.25 μg/kg/min, amiodarone 200 mg twice daily, and dabigatran 150 mg twice daily for stroke prevention secondary to atrial fibrillation. Upon notification of organ availability, the patient was admitted to the hospital for transplant surgery, with her last dose of dabigatran taken approximately 36 hours before admission. Coagulation studies indicated normal activated partial thromboplastin time, slightly elevated international normalized ratio of 1.2, and elevated thrombin time (TT) of 90.6 seconds (upper limit of normal 19.9 seconds). A hemodialysis catheter was emergently placed and dialysis was initiated. One hour after initiation, TT decreased to 65.5 seconds. After 2.5 hours of dialysis, TT further decreased to 60.2 seconds; at that time, the patient underwent transplantation with no abnormal bleeding during or following surgery.
Minimal data exist on techniques to reverse the effects of dabigatran in cases of bleeding or emergent surgery. This case examines the efficacy of hemodialysis to decrease dabigatran's effect on clotting assays prior to surgery to reduce the risk of bleeding. In this case, a TT of 60.2 seconds with recent dabigatran administration did not result in abnormal bleeding associated with cardiac surgery.
To our knowledge, this case report represents the first published data on the effects of hemodialysis on dabigatran removal and reversal of anticoagulation associated with dabigatran before surgery. The routine use of preoperative hemodialysis in patients on dabigatran is not recommended; however, the potential efficacy in such circumstances is supported by the successful results in this case.
描述 1 例在心脏移植前进行血液透析以逆转达比加群的作用并降低与手术相关出血风险的病例。
1 例 59 岁女性，患有心力衰竭和心房颤动，因心力衰竭入院接受同种异体心脏移植。她在家中一直服用米力农 0.25μg/kg/min、胺碘酮 200mg 每日 2 次和达比加群 150mg 每日 2 次，以预防因心房颤动引起的卒中。在得知器官供体可用后，患者因移植手术而入院，最后一次服用达比加群的时间约为入院前 36 小时。凝血研究显示，激活部分凝血活酶时间正常，国际标准化比值稍高（1.2），凝血酶时间（TT）升高至 90.6 秒（正常值上限 19.9 秒）。紧急放置血液透析导管并开始透析。开始透析后 1 小时，TT 降至 65.5 秒。透析 2.5 小时后，TT 进一步降至 60.2 秒；此时，患者接受移植手术，术中及术后均无异常出血。
在出血或紧急手术的情况下，逆转达比加群作用的技术仅有少量数据。本病例探讨了在手术前通过血液透析降低达比加群对凝血检测的影响，以降低出血风险。在本例中，TT 为 60.2 秒，且近期使用达比加群，但并未导致与心脏手术相关的异常出血。
据我们所知，本病例报告代表了关于血液透析对达比加群清除和逆转达比加群抗凝作用的首次发表数据，这些作用与手术前使用达比加群相关。不推荐在服用达比加群的患者中常规进行术前血液透析；然而，该病例的成功结果支持在这种情况下使用血液透析的潜在疗效。
