Idarucizumab for the Reversal of Dabigatran in Patients Undergoing Heart Transplantation

Abstract

Purpose Atrial fibrillation is common among patients listed for HTx. NOACs offer several advantages over VKAs. However, in case of HTx surgery an immediate normalization of coagulation is required. Idarucizumab is a monoclonal antibody fragment that was developed to neutralize the activity of the direct thrombin inhibitor dabigatran. Although RE-VERSE AD included 202 patients requiring emergent procedures, there have been only 2 reports of idarucizumab use in heart transplant surgery to date. Methods At time of listing, patients requiring anticoagulation because of non-valvular atrial fibrillation, CHA2DS2VASc 2 and without LVAD or end-stage renal failure, were started on or switched to dabigatran. Upon availability of a donor organ, dabigatran was neutralized with 5 g of intravenous idarucizumab, immediately prior to induction of anaesthesia. Results Dabigatran concentration and aPTT after idarucizumab are represented in Figure 1. During surgery, patients received on average 1.0 unit of packed cell transfusion, 4.1 units fresh frozen plasma, 0.9 pools platelets and 587 mL blood that was recovered via cell salvage. Two patients needed re-intervention because. No adverse reactions or unexpected events that could potentially be related to idarucizumab administration were noted. There were no thrombotic complications. Conclusion This is the largest report describing the use of idarucizumab to normalize coagulation in patients on dabigatran awaiting HTx. Administration of idarucizumab led to a sustained and complete biochemical reversal, without thrombotic complications, and without interfering with heparinization for cardiopulmonary bypass. In conclusion, the availability of an immediately-acting complete reversal agent makes dabigatran an attractive choice for non-VAD patients with non-valvular atrial fibrillation who are listed for heart transplantation.