Dabigatran anticoagulation and Stanford type A aortic dissection: lethal coincidence

Stein, Paul D.; Bosshart, Marco; Brand, Brigitte; Schlicker, A.; Spahn, Donat R.; Béttex, Dominique

doi:10.1111/aas.12303

Cited by 18 publications

(12 citation statements)

References 35 publications

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“…Because emergency surgery in patients under dabigatran treatment has been associated with severe or even fatal bleeding, it is recommended that DOACs be discontinued at least 48 h before cardiac surgery. [78][79][80] DOACs may be bridged by heparins in patients with acute thrombotic events o 4 weeks. The half-life of DOACs may be prolonged in case of impaired renal function (Table 3).…”

Section: Vitamin K Antagonistsmentioning

confidence: 99%

2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery

Boer¹,

Meesters²,

Milojevic³

et al. 2018

Journal of Cardiothoracic and Vascular Anesthesia

330

192

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Section: Vitamin K Antagonistsmentioning

confidence: 99%

2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery

Boer¹,

Meesters²,

Milojevic³

et al. 2018

Journal of Cardiothoracic and Vascular Anesthesia

330

192

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“…We have read an interesting case report by Stein et al 1 on aortic dissection in a patient on dabigatran. We have had a similar case of a female, 83 years old, under dabigatran therapy for permanent atrial fibrillation, admitted to the emergency room with a type A aortic dissection.…”

Section: Sirmentioning

confidence: 98%

Dabigatran anticoagulation and Stanford type A aortic dissection: not a lethal coincidence

Marchetti

Giuliani

Urbinati

et al. 2015

Acta Anaesthesiol Scand

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Sir,We have read an interesting case report by Stein et al. 1 on aortic dissection in a patient on dabigatran. We have had a similar case of a female, 83 years old, under dabigatran therapy for permanent atrial fibrillation, admitted to the emergency room with a type A aortic dissection.Six hours earlier she had taken a 110 mg dose of dabigatran.The patient underwent a session of dialysis to reduce the plasma concentration of dabigatran but after an initial reduction it started to rise again 2 h after the end of the session. Admission laboratory tests showed a prothrombin time 190 s (normal 10.5-13.5 s), activated partial thromboplastin time 55 s (normal 25-37 s) and thrombin time > 150 s (normal 14-20 s). Dabigatran level was 240 ng/ml as measured by Hemoclot assay within the assay working range of 50-400 ng/ml. Renal function was impaired with estimated glomerular filtration rate 48 ml/ min.The post-dialysis concentration of dabigatran was 140 ng/ml and reached 100 ng/ml before surgery so factor VIII inhibitor (FEIBA) 20 U/kg was necessary to counter the anticoagulant activity with almost complete normalization of coagulation.The ascending aortic replacement was successfully performed.Other authors report the increase in dabigatran concentration and clotting times after dialysis probably due to the redistribution of dabigatran bound to plasma proteins and the shift out of the extravascular compartment. Chang and colleagues suggest to make several short dialytic cycles or a prolonged session in order to limit the rebound. 2 At the time we treated this case the antidote, idarucizumab, was not available in the facility where the patient was admitted. This monoclonal antibody, however, is indicated in similar scenarios for the emergency reversal of anticoagulation. 3 Haemodialysis is beneficial in mitigating bleeding risk and can be safely performed prior to emergency surgery but a rebound increase in dabigatran levels may be expected in the first hours after dialysis and FEIBA administration is a viable approach for the prevention of perioperative control of bleeding. References 1. Stein P, Bosshart M, Brand B, Schliker A, Spahn DR, Bettex D. Dabigatran anticoagulation and Stanford type A aortic dissection: lethal coincidence.

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“…We have read the recent case report by Crapelli et al with great interest. 1 Their case and others 2,3 highlight the importance of bleeding management in dabigatran-treated patients undergoing emergency cardiovascular procedure. We agree with the authors that idarucizumab (Praxibind; Behringer-Ingelheim, Germany) is important in reducing the risk of hemorrhagic death, but clinicians should be aware of high morbidity and mortality of these patients due to underlying cardiovascular conditions.…”

Section: Idarucizumab For Dabigatran Reversal In Emergency Type-a Aormentioning

confidence: 99%

“…5 The median age of these patients was 76 years old, similar to our patient and others (76 to 82 years old). [1][2][3] Hemostasis during the procedure was clinically judged to be adequate in 92% of cases, but with a high mortality rate of 23.1%, mainly due to cardiovascular causes.…”

Section: Idarucizumab For Dabigatran Reversal In Emergency Type-a Aormentioning

confidence: 99%

Idarucizumab for Dabigatran Reversal in Emergency Type-A Aortic Dissection

Henderson

Deshpande

Williams

et al. 2017

Journal of Cardiothoracic and Vascular Anesthesia

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Dabigatran anticoagulation and Stanford type A aortic dissection: lethal coincidence

Abstract: After reviewing the literature, we summarize the limited treatment options and show possible approaches for patients treated with dabigatran needing emergency surgery.

Cited by 18 publications

References 35 publications

2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery

2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery

Dabigatran anticoagulation and Stanford type A aortic dissection: not a lethal coincidence

Idarucizumab for Dabigatran Reversal in Emergency Type-A Aortic Dissection

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