Use of Idarucizumab to Revert the Anticoagulant Effect of Dabigatran in Heart Transplant Surgery: An Institutional Experience

Abstract

Heart transplant is a surgical procedure with a high risk of perioperative bleeding in patients with a previous history of sternotomy, congestive liver disease, and/or use of oral anticoagulants. Anticoagulation is usually done with coumarin agents (warfarin, acenocoumarol), while on the waiting list, vitamin K is available allowing for partial reversal of the anticoagulant effect, although with variable INR and risk of uncontrolled bleeding. Direct oral anticoagulants have emerged as an alternative to the use of coumarins in patients with nonvalvular atrial fibrillation (NVAF). The main disadvantage of this group of drugs is that there was no specific reversal agent available that would allow an urgent reversal of the anticoagulant effect. The recent commercialization of idarucizumab (specific reversal agent) has allowed patients with NVAF on the waiting list for heart transplant to be treated with dabigatran. We present the case of a patient with advanced chronic heart failure and NVAF anticoagulated with dabigatran, who underwent urgent heart transplant after administration of idarucizumab, without complications derived from its use or from anticoagulation.

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

“…The EHRA 2017 practical guide mentions reversal agents for dabigatran and FXa-inhibitors, at that time still under investigation, and administration of prothrombin complex concentrate (PCC) or activated PCC acknowledging, though, that efficacy and safety of this treatment for active bleeding has not been firmly established ( 12 ). A couple of case series ( 21 , 22 ) and a case report ( 23 ) together have described the use of the dabigatran antidote idarucizumab in the cardiac surgery setting, reporting optimal perioperative hemostasis being achieved in up to 93% of treated patients. The authors outlined these results as encouraging but highlighted the need for more studies to corroborate these observations, especially regarding cost and clinical effectiveness, and mortality benefit.…”

Use of direct‐acting oral anticoagulants in solid organ transplantation: A systematic review

“…The use of idarucizumab in the setting of transplant recipients has limited data including case reports and small cohort experiences. There have been several case reports using this reversal modality in the setting of transplant surgery with success 55–61 . In a series of 10 patients receiving idarucizumab in the setting of heart transplantation, two patients (20%) required re‐intervention because of bleeding which was similar to a historical control group 60 .…”

A Review of Direct-acting Oral Anticoagulants and Their Use in Solid Organ Transplantation

“…Notwithstanding the availability of a reversal agent, dabigatran use among transplant candidates has declined because of its dependence on renal elimination and higher rates of bleeding than the oral factor Xa inhibitors. 11,12,[26][27][28][29][30][31] Anticoagulant reversal is further detailed in the section on the periprocedural period.…”