title: Safe use of hemodialysis for dabigatran removal before cardiac surgery.
abstract: OBJECTIVE
  To describe a case in which hemodialysis was performed before cardiac transplantation in an attempt to reverse the effects of dabigatran and reduce the risk of bleeding associated with surgery.
  
  
  METHODS
  A 59-year-old female with heart failure and atrial fibrillation was admitted for orthotropic heart transplant. She had been stable at home with continuous milrinone therapy 0.25 μg/kg/min, amiodarone 200 mg twice daily, and dabigatran 150 mg twice daily for stroke prevention secondary to atrial fibrillation. Upon notification of organ availability, the patient was admitted to the hospital for transplant surgery, with her last dose of dabigatran taken approximately 36 hours before admission. Coagulation studies indicated normal activated partial thromboplastin time, slightly elevated international normalized ratio of 1.2, and elevated thrombin time (TT) of 90.6 seconds (upper limit of normal 19.9 seconds). A hemodialysis catheter was emergently placed and dialysis was initiated. One hour after initiation, TT decreased to 65.5 seconds. After 2.5 hours of dialysis, TT further decreased to 60.2 seconds; at that time, the patient underwent transplantation with no abnormal bleeding during or following surgery.
  
  
  CONCLUSIONS
  Minimal data exist on techniques to reverse the effects of dabigatran in cases of bleeding or emergent surgery. This case examines the efficacy of hemodialysis to decrease dabigatran's effect on clotting assays prior to surgery to reduce the risk of bleeding. In this case, a TT of 60.2 seconds with recent dabigatran administration did not result in abnormal bleeding associated with cardiac surgery.
  
  
  CONCLUSIONS
  To our knowledge, this case report represents the first published data on the effects of hemodialysis on dabigatran removal and reversal of anticoagulation associated with dabigatran before surgery. The routine use of preoperative hemodialysis in patients on dabigatran is not recommended; however, the potential efficacy in such circumstances is supported by the successful results in this case.
authors.affiliation: Allegheny General Hospital, Pittsburgh, PA, USA. mattwanek@gmail.com
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Wanek
authors.forename: Edward T
authors.initials: ET
authors.lastname: Horn
authors.forename: Subbarao
authors.initials: S
authors.lastname: Elapavaluru
authors.forename: Samuel C
authors.initials: SC
authors.lastname: Baroody
authors.forename: George
authors.initials: G
authors.lastname: Sokos
mesh_terms: D000991:Antithrombins / Q000302:isolation & purification*; D001562:Benzimidazoles / Q000302:isolation & purification*; D000069604:Dabigatran; D005260:Female; D016027:Heart Transplantation; D006801:Humans; D008875:Middle Aged; D006435:Renal Dialysis; D013918:Thrombin Time; D015091:beta-Alanine / Q000031:analogs & derivatives* / Q000302:isolation & purification
chemical_list: D000991:Antithrombins; D001562:Benzimidazoles; D015091:beta-Alanine; D000069604:Dabigatran