Combined Antithrombin and Heparin Supplementation to Blood for Restoring Heparin Responsiveness After Andexanet Alfa Exposure: An In Vitro Model
Abstract
Background:
Andexanet alfa, a Gla-domainless mutant factor Xa (GDXa), reverses oral FXa inhibitors but can cause severe heparin resistance during cardiopulmonary bypass (CPB). Antithrombin (AT) supplementation may mitigate this effect, though dosing evidence is limited.
Methods
We evaluated in vitro the effectiveness of combined heparin and AT in restoring heparin responsiveness after andexanet exposure. Whole blood and platelet-poor plasma from surgical patients on CPB were spiked with andexanet at target concentrations of 2.9 and 4 µM, respectively. Heparin responsiveness was assessed using kaolin-activated clotting time (ACT), ellagic acid-activated thromboelastometry (INTEM), and thrombin generation (TG) assays. Heparin alone or with AT (0.8–3.1 µM in whole blood; 1.1–4.4 µM in plasma) simulated clinical AT dosing (25–100 U/kg).
Results
Andexanet shortened ACT by 68% versus native on-CPB blood. Heparin alone or low-dose AT failed to restore ACT, while high-dose AT with heparin prolonged ACT to > 400 s. INTEM showed a 102% increase in clotting time with moderate-dose AT, with modest α-angle and MCF reductions (≤ 16%). In plasma, high-dose AT plus heparin increased TG lag time ∼5-fold, with thrombin peak and velocity reduced by 86%.
Conclusion
High-dose AT with heparin mitigates andexanet-induced heparin resistance in vitro, though residual TG and clot formation suggest ongoing thrombotic risk, warranting further study.