Andexanet Alfa in Urgent Cardiac Surgery: A Case Report of Edoxaban Reversal for Acute Hemopericardium.

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.