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Indications of non-vitamin K antagonist oral anticoagulants (NOACs), consisting of two types: direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitor (rivaroxaban, apixaban, and edoxaban), have expanded over the last few years. Accordingly, increasing number of patients presenting for surgery are being exposed to NOACs, despite the fact that NOACs are inevitably related to increased perioperative bleeding risk. This review article contains recent clinical evidence-based up-to-date recommendations to help set up a multidisciplinary management strategy to provide a safe perioperative milieu for patients receiving NOACs. In brief, despite the paucity of related clinical evidence, several key recommendations can be drawn based on the emerging clinical evidence, expert consensus, and predictable pharmacological properties of NOACs. In elective surgeries, it seems safe to perform high-bleeding risk surgeries 2 days after cessation of NOAC, regardless of the type of NOAC. Neuraxial anesthesia should be performed 3 days after cessation of NOACs. In both instances, dabigatran needs to be discontinued for an additional 1 or 2 days, depending on the decrease in renal function. NOACs do not require a preoperative heparin bridge therapy. Emergent or urgent surgeries should preferably be delayed for at least 12 h from the last NOAC intake (better if > 24 h). If surgery cannot be delayed, consider using specific reversal agents, which are idarucizumab for dabigatran and andexanet alfa for rivaroxaban, apixaban, and edoxaban. If these specific reversal agents are not available, consider using prothrombin complex concentrates.

Off-pump coronary surgery requires mechanical cardiac displacement yielding bi-ventricular systolic and diastolic dysfunction. Although transient, subsequent hemodynamic deterioration can bear dismal prognosis and at the extreme, emergent on-pump conversion may be needed, which is associated with undesirably high morbidity and mortality rates. Thus, proper decisions should be made based on objective hemodynamic targets whether surgery can be proceeded before opening the coronary artery.Hemodynamic management should prioritize the avoidance of perplexing myocardial oxygen-supply demand balance, which include maintenance of mean arterial pressure above 70 mmHg while avoiding increase in oxygen demand beyond the patient's coronary reserve. Maintenance of mixed venous oxygen saturation above 60%, which reflects the lower limit of the adequacy of global oxygen-supply demand balance, seems also important not to jeopardize the patient's prognosis. Above all, severe mechanical cardiac constraint incurring compressive syndromes that cannot by overcome by manipulating major determinants of cardiac output should be avoided. To rule out uncompromising form of cardiac constraint, central venous pressure should not equal or exceed the pulmonary artery diastolic (or occlusion) pressure, which would reflect tamponade physiology. In addition, transesophageal echocardiography should rule out mechanical cardiac displacementinduced ventricular interdependence, dyskinesia, severe mitral regurgitation, and left ventricular outflow tract obstruction with or without systolic motion of the anterior leaflet of the mitral valve, which cannot be tolerated during the period of grafting. Also, careful inspection for gas bubbles in the ascending aorta should be performed to prevent rare causes of hemodynamic collapse by massive gas embolism obstructing the right coronary ostium.