Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany.
Klinik für Thorax- und Kardiovaskularchirurgie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany.
J Thorac Cardiovasc Surg. 2021 May;161(5):1864-1874.e2. doi: 10.1016/j.jtcvs.2019.11.119. Epub 2019 Dec 17.
Recommendations for perioperative management of direct oral anticoagulant (DOAC) treatment in cardiac surgery are lacking. To establish a standardized approach for these patients, we compared hemorrhagic complications and clinical outcomes in patients on DOAC medication, patients on vitamin K antagonists (VKA), and patients without preoperative anticoagulation.
All 3 groups underwent major cardiac surgery and were retrospectively analyzed: patients on DOAC were advised to take their last DOAC dose 4 days before hospital admission, and DOAC plasma levels were measured the day before surgery. In patients with plasma levels of >30 ng/mL, surgery was postponed until plasma level was below this threshold level. Postoperative chest tube drainage, bleeding complications, use of blood products, and thromboembolic events were collected for all groups.
A total of 5439 patients no anticoagulation, 239 patients on VKA, and 487 patients on DOAC medication were included between April 2014 and July 2017. Adjusted postoperative chest tube drainage did not differ between the DOAC and VKA groups for the strategy applied in this study (380 mL/12 hours vs 360 mL/12 hours). Moreover, secondary endpoint measures, such as rethoracotomy (30 [6.16%] vs 15 [6.28%]), 30-day-mortality 12 [2.46%] vs 7 [2.93%]), blood-product use, and stroke, were not significantly different through implementation of our standardized study management (P > .05).
Our standardized management for perioperative discontinuation of DOAC therapy may provide a safe approach to minimize hemorrhagic complications in cardiac surgery in patients on DOACs.
心脏外科手术中直接口服抗凝剂（DOAC）治疗的围手术期管理建议尚缺乏。为了为这些患者制定标准化的方法，我们比较了正在服用 DOAC 药物、维生素 K 拮抗剂（VKA）和未进行术前抗凝的患者的出血并发症和临床结局。
所有 3 组患者均接受了主要心脏手术，并进行了回顾性分析：建议正在服用 DOAC 的患者在入院前 4 天服用最后一剂 DOAC，并在手术前一天测量 DOAC 血浆水平。对于血浆水平>30ng/ml 的患者，手术将推迟至该水平以下。收集了所有组的术后胸腔引流管引流量、出血并发症、血液制品的使用和血栓栓塞事件。
2014 年 4 月至 2017 年 7 月期间，共有 5439 例无抗凝治疗、239 例服用 VKA 和 487 例服用 DOAC 药物的患者纳入本研究。对于本研究中应用的策略，DOAC 和 VKA 组的调整后术后胸腔引流管引流量没有差异（380ml/12 小时比 360ml/12 小时）。此外，通过实施我们的标准化研究管理，次要终点措施，如再次开胸（30[6.16%]比 15[6.28%]）、30 天死亡率 12[2.46%]比 7[2.93%]）、血液制品的使用和中风，没有显著差异（P>.05）。
我们对 DOAC 治疗围手术期停药的标准化管理可能为心脏手术中服用 DOAC 的患者最小化出血并发症提供一种安全的方法。
