Background: Heart Transplantation (HT) is often an emergent cardiac surgery that needs optimal correction of hemostasis.
Many patients proposed to HT are under anticoagulation, mainly because of non-valvular atrial fibrillation (NV-AF). The prompt reversal of anticoagulation gains an extremely important role in the outcome of the surgery itself.
Idarucizumab is a monoclonal antibody fragment that efficiently neutralizes the activity of dabigatran, being approved for emergency surgery/urgent procedures or life‐threatening or uncontrolled bleeding.

Aims: Case report

Methods: A 40-year-old male with hypertrophic cardiomyopathy/non-compaction cardiomyopathy with decrease of biventricular systolic function (class IV NYHA) and multiple comorbidities was included in an active list for HT. He was under dabigatran 150mg bid due to NV-AF, among other medications. Dabigatran was chosen due to the availability of idarucizumab in the eminence of HT surgery.
As soon as a compatible organ donor was available, patient was notified. Last dose of dabigatran was taken 4h before hospital admission. Idarucizumab 5g iv was administered before HT. Coagulation tests, including dabigatran concentration assessment, were performed before and after idarucizumab administration.

Results: At admission, activated partial thromboplastin time (aPTT) was 75,1 seconds (s) (N: 24,2-36,4s) and dabigatran concentration was 460 ng/mL. Fifteen minutes after idarucizumab administration, aPTT was 29,5 s and dabigatran concentration was 15 ng/mL..
Orthotopic heart transplantation requiring cardiopulmonary by-pass (CPB) was performed. During surgery , 4 FFP, 5 RBC and 1 pool of platelets were transfused.
The surgery was performed without major incidentes. Patient was discharged 30 days after surgery.

Conclusions: In this case, idarucizumab successfully neutralized dabigatran, enabling HT with CPB, without thrombotic ou bleeding complications.
The availability of a specific reversal agent against a direct oral anticoagulant is a valuable therapeutic weapon in patients needing emergent reversal of anticoagulantion. In our hospital, dabigatran is included in HT protocol when patients need anticoagulation and do not present contraindications for it.

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ISTH Congress Abstracts - https://abstracts.isth.org/abstract/reversal-of-dabigatran-by-idarucizumab-in-heart-transplantation-surgery-a-case-report/