LAUSR

Difficulties of warfarin usage and the convenience of Direct-Acting Oral Anticoagulant (DOAC) have changed the anticoagulation strategy.1 Vitamin K antagonists are being increasingly altered to DOAC therapy for suitable clinical settings. In near future, surgeons will more frequently perform emergency operations for patients on DOACs therapy. This will eventually bring in an excessive risk of postoperative bleeding following emergency cardiac surgery. Cardiopulmonary bypass (CPB)-induced coagulation defects become more remarkable in aortic dissection cases, as fibrin degradation products and D-dimer levels increase.2 For this reason, bleeding management of the patients on factor Xa inhibitors is even more difficult in these cases. Apixaban, with a rapid onset of action and a half-life of 8-14 hours, is one of the most frequently used factor Xa inhibitors.3 It is used twice a day 5 mg or 2.5 mg; the dose is adjusted according to weight and kidney function. For elective surgery, cessation is recommended 2-3 days before the procedure. In urgent cases, waiting up to 24 hours, if possible, reduces bleeding complications. Residual anticoagulant activity decreases 50% at 12 hours and below 25% at 24 hours after drug cessation.4 In some case reports, activated prothrombin complex concentrate 25 IU/kg could reverse the anticoagulant effect of apixaban.5 Nevertheless, there is no consensus and clear guidelines on reversal management. We present a patient with acute type A aortic dissection on apixaban, needing emergency cardiac surgery. The discussion addresses Apixaban’s pharmacokinetics and key points of emergency cardiac surgery on Apixaban.