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 re