Invited Commentary: Initial Experience with Direct Oral Anticoagulants in the Perioperative Setting

The perioperative period represents a challenging situation for antithrombotic management. There is a lack of data on the perioperative use of direct oral anticoagulants (DOACs). We sought to describe the initial perioperative experience with these agents at our institution. Patients who were taking dabigatran, rivaroxaban, or apixaban prior to cardiac valve or coronary artery bypass surgery were included if they were at least 18 years old and had a platelet count > 100,000 and hemoglobin > 8g/dl. We evaluated bleeding and thromboembolic events. Dabigatran, rivaroxaban, and apixaban were stopped a median (IQR) of 5 (4-6), 4 (3-7), and 9 (5-14) days prior to surgery (p=0.35). Bridge therapy was used in 17 (30.9 %) patients. There were 10 (18.2 %) bleeding events and 1 (1.8 %) thromboembolism. In this single-center report, oral anticoagulation with DOACs was suspended earlier than recommended in patients undergoing major cardiac surgery. Bridge therapy was used frequently and associated with a non-statistically significant increase in bleeding. These findings highlight the need for larger studies.