Intraoperative antithrombotic drug removal during heart transplantation: a case series from the international safe and timely antithrombotic removal (STAR) registry

Background: Patients on heart transplant waiting lists are often on antithrombotic (AT) drugs. Emergency orthotopic heart transplantation (OHT) when performed on such patients without optimal washout periods increases the risk of severe perioperative bleeding. Intraoperative AT removal by hemoadsorption may mitigate excess bleeding risks.

Methods: The international Safe and Timely Antithrombotic Removal (STAR) registry captures real-world outcomes (ClinicalTrials.gov# NCT05077124). Included patients were on ticagrelor or direct-acting oral anticoagulants (DOACs) undergoing emergent OHT. Hemoadsorption was integrated into the cardiopulmonary bypass (CPB) circuit. Bleeding was assessed with the universal definition of perioperative bleeding (UDPB) and volume of chest tube drainage (CTD).

Results: Seven patients were included (3 ticagrelor, 2 apixaban, 2 dabigatran; mean age 39.1 ± 11.1 years; 4 females). Mean time from the last AT dose to surgery was 29.4 ± 13.4 hours. Mean CPB duration was 206.0 ± 56.9 minutes with a mean device flow of 340 ± 126 ml. There were no massive bleeding events (UDPB 4), surgical revisions to control bleeding, or deaths within 30 days. Severe bleeding (UDPB 3) occurred in 1/7 (14.3%). Mean 12-hour and 24-hour CTD were 385.7 ± 263.4 m and 586.1 ± 315.0 ml, respectively. No device-related adverse events were reported.

Conclusions: This case series from the ongoing STAR registry shows that intraoperative AT removal is simple and potentially effective in minimizing serious perioperative bleeding in patients on ticagrelor or DOACs undergoing OHT. Prospective, controlled studies in larger cohorts are needed to validate these promising observations.