Andexanet Alfa in Urgent Cardiac Surgery: A Case Report of Edoxaban Reversal for Acute Hemopericardium.
Research article published in The American journal of case reports (2025)
Abstract
BACKGROUND Antidotes to non-vitamin K oral anticoagulants (NOAK) like idarucizumab and andexanet alfa have been approved for reversing the effects of dabigatran and apixaban/rivaroxaban, respectively. However, andexanet alfa is not approved for reversing edoxaban. Current guidelines recommend using specific reversal agents in emergencies, but they do not support andexanet alfa for edoxaban reversal. This study illustrates the off-label use of andexanet alfa for edoxaban reversal in a case of acute hemopericardium requiring urgent cardiac surgery, addressing the practical challenges and clinical outcomes. CASE REPORT We report the case of a 71-year-old woman who required urgent cardiac surgery following acute pericardial tamponade caused by hemopericardium during right-heart catheterization. After emergency pericardiocentesis, andexanet alfa was administered to address any residual effects of edoxaban (Lixiana), along with protamine to reverse the effects of heparin. The patient was transferred in stable condition for cardiac surgery, where a right ventricular perforation responsible for the hemopericardium was sutured, and mitral valve replacement was performed via cardiopulmonary bypass (CPB) due to severe mitral valve regurgitation. No adverse cerebrovascular, hemorrhagic, or thromboembolic events were observed. CONCLUSIONS This case demonstrates an unconventional off-label use of andexanet alfa to stabilize a patient on edoxaban. Although the patient did not have any adverse effects, the thromboembolic risks of andexanet alfa and potential heparin resistance warrant cautious use, especially before cardiac surgery. Successful management was achieved through a multidisciplinary approach. Further research is needed to evaluate the safety and efficacy of andexanet alfa in patients on edoxaban therapy.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
BACKGROUND Antidotes to non-vitamin K oral anticoagulants (NOAK) like idarucizumab and andexanet alfa have been approved for reversing the effects of dabigatran and apixaban/rivaroxaban, respectively.
Why This Matters for Hirudotherapy
This single case report describes off-label use of andexanet alfa (an approved factor Xa-inhibitor antidote, but not approved for edoxaban) together with protamine to manage a 71-year-old woman with acute hemopericardium and tamponade requiring urgent cardiac surgery while on edoxaban; the patient was stabilized and underwent surgery with no observed cerebrovascular, hemorrhagic or thromboembolic events. For ASH the value is contextual rather than direct: it illustrates the real-world challenge of reversing anticoagulation before an emergent procedure, a safety consideration that parallels questions about managing bleeding when a patient on anticoagulants also receives leech therapy, whose saliva adds its own anticoagulant load. As an explicit single-patient case report with an off-label intervention, it cannot establish efficacy or safety; the authors themselves flag thromboembolic risk and call for further research, and it makes no statement about hirudotherapy.
Citation
Andexanet Alfa in Urgent Cardiac Surgery: A Case Report of Edoxaban Reversal for Acute Hemopericardium.
Al Mawed M et al. · The American journal of case reports, 2025
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