Management of Direct Oral Anticoagulants in Acute Type A Aortic Dissection.

Background: Direct oral anticoagulants (DOACs) are a commonly used class of anti-coagulants that may complicate surgical management of acute Type A aortic dissection (ATAAD).

Methods:  Surgical management and clinical courses were described for patients who presented to our institution with ATAAD while taking DOACs, after FDA approval of the two currently available reversal agents. A thorough literature review was completed for cases of administration of DOAC reversal agents in ATAAD.

Results:  The only patient treated with andexanet-alfa had heparin insensitivity while on cardiopulmonary bypass. Four other patients were successfully managed with a combination of surgical delay and factor repletion.

Conclusion:  This case series demonstrates that preoperative management of DOACs in patients with ATAAD may employ factor repletion with success. Literature review demonstrated a safety signal for heparin insensitivity or pump thrombosis when andexanet-alfa was administered before or while on cardiopulmonary bypass or extracorporeal membrane oxygenation. Our institutional clinical practice guidelines recommend against administration of andexanet-alfa within 4 to 6 hours before heparinization for surgery in ATAAD but recommend considering andexanet-alfa administration when there is life-threatening bleeding after heparin reversal that is thought to be due to Xa-inhibition with laboratory evidence of elevated anti-Xa activity.