Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands.
Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands.
Eur J Cardiothorac Surg. 2023 Oct 4;64(4). doi: 10.1093/ejcts/ezad340.
Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize the current evidence and provide literature-based recommendations for the management of patients on DOACs in the perioperative phase.
A general literature review was conducted on the pharmacology of DOACs and for recommendations on the management of cardiac surgical patients on DOACs. Additionally, we performed a systematic review for studies on the use of direct DOAC reversal agents in the emergency cardiac surgical setting.
When surgery is elective, the DOAC cessation strategy is relatively straightforward and should be adapted to the renal function. The same approach applies to urgent cases, but additional DOAC activity drug level monitoring tests may be useful. In emergency cases, idarucizumab can be safely administered to patients on dabigatran in any of the perioperative phases. However, andexanet alfa, which is not registered for perioperative use, should not be administered in the preoperative phase to reverse the effect of factor Xa inhibitors, as it may induce temporary heparin resistance. Finally, the administration of (activated) prothrombin complex concentrate may be considered in all patients on DOACs, and such concentrates are generally readily available.
DOACs offer several advantages over vitamin K antagonists, but care must be taken in patients undergoing cardiac surgery. Although elective and urgent cases can be managed relatively straightforwardly, the management of emergency cases requires particular attention.
关于正在使用直接口服抗凝剂（DOAC）进行择期、紧急和急诊手术的患者的管理，文献资料十分有限。因此，我们总结了当前的证据，并为围手术期 DOAC 患者的管理提供了基于文献的建议。
对 DOAC 的药理学和心脏外科患者使用 DOAC 的管理建议进行了全面的文献回顾。此外，我们还对直接 DOAC 逆转剂在紧急心脏外科手术环境中的使用进行了系统评价。
当手术为择期手术时，DOAC 停药策略相对简单，应根据肾功能进行调整。同样的方法也适用于紧急情况，但可能需要额外的 DOAC 活性药物水平监测测试。在紧急情况下，达比加群的患者可以安全地使用依达鲁珠单抗，无论在围手术期的哪个阶段。然而，在术前阶段不应使用尚未注册用于围手术期的andexanet alfa 来逆转 Xa 因子抑制剂的作用，因为它可能导致暂时的肝素抵抗。最后，所有使用 DOAC 的患者均可考虑使用（活化）凝血酶原复合物浓缩物，并且这些浓缩物通常易于获得。
DOAC 相对于维生素 K 拮抗剂具有许多优势，但在接受心脏手术的患者中必须谨慎。尽管择期和紧急情况可以相对简单地进行管理，但紧急情况的管理需要特别注意。
