Management of perioperative bleeding risk in patients on antithrombotic medications undergoing cardiac surgery—a systematic review

Background: Antithrombotic drugs increase the risk of bleeding, especially in patients who need

urgent surgery without an adequate wash-out period. This review aims to evaluate perioperative bleeding

complications in patients on dual antiplatelet therapy (DAPT) or direct-acting oral anticoagulants (DOACs)

undergoing high-bleeding risk cardiovascular surgery and to present currently available potential solutions to

mitigate antithrombotic therapy-related bleeding complications.

Methods: As a first step, we searched for relevant articles, over the last 10 years, in Medline (PubMed) and

abstracted clinical information based on pre-defined criteria for bleeding complications. In the next step,

an additional search evaluating potential solutions to mitigate bleeding complications was performed. The

literature screening and selection process followed the principles derived from the PRISMA statement.

Results: From all reviewed studies, a total of 19 articles could be included evaluating the risk for bleeding

in cardiac surgery related to DAPT or DOACs and 10 papers evaluating antithrombotic drug reversal or

removal in the setting of cardiovascular surgery. Reported bleeding rates ranged between 18% and 41%.

The variability of the reported data is remarkable. Idarucizumab is reported to provide optimal perioperative

hemostasis in up to 93% of patients. It has been observed that andexanet alfa causes unresponsiveness to

the anticoagulant effects of heparin. Antithrombotic removal by intraoperative hemoadsorption is found to

be associated with a significant decrease in re-thoracotomy rate, overall procedure duration, administered

transfusion volumes, chest-tube drainage, and length of hospitalization.

Discussion: Bleeding complications in patients treated with DAPT or DOACs in cardiac surgery are high.

New costly reversal agents are available but have not been sufficiently tested in the cardio-surgical setting

so far. Interestingly, bleeding-related complications seem to be effectively reduced by applying innovative

intraoperative hemoadsorption techniques. Expected results from the ongoing trials should provide better

insights concerning the efficacy and safety of several potential solutions. Currently, the variability of reports

and the deficit of high-quality studies in this specific setting represent the major limitation for the unbiased

conclusion of this review.