Managing Life-Threatening Bleeding in Patient with High Plasma Concentration of Dabigatran with Thromboelastogram, Idarucizumab and Renal Replacement Therapy

We present a case of patient with spontaneous cardiac tamponade related to a very high 2-plasma concentration of dabigatran, an oral direct-acting thrombin inhibitor. By selectively inhibiting thrombin alone, dabigatran may have antithrombotic efficacy while preserving some other hemostatic mechanisms in the coagulation system and thus potentially mitigating the risk of bleeding. Nonetheless, serious bleeding can occur with dabigatran. We illustrate the management of this life threatening hemorrhagic complication by the combination of cardiac surgery, antagonization of the anticoagulant effect (using Idarucizumab, an humanized monoclonal antibody fragment and continuous renal replacement therapy), and monitoring of the effects on coagulation by thromboelastogram.