55
6.5.2. Cardiac Surgery — LAA Exclusion/Excision
COR LOE
Recommendations
1 A 1. In patients with AF undergoing cardiac surgery with a
CHAD
2
DS
2
-VASc score ≥2 or equivalent stroke risk, surgical
LAA exclusion, in addition to continued anticoagulation, is
indicated to reduce the risk of stroke and systemic embolism.
1 A 2. In patients with AF undergoing cardiac surgery and LAA
exclusion, a surgical technique resulting in absence of flow
across the suture line and a stump of <1 cm as determined by
intraoperative transesophageal echo should be used.
2b A 3. In patients with AF undergoing cardiac surgery with
CHAD
2
DS
2
-VASc score ≥2 or equivalent stroke risk, the
benefit of surgical LAA exclusion in the absence of continued
anticoagulation to reduce the risk of stroke and systemic
embolism is uncertain.
6.6. Active Bleeding on Anticoagulant Therapy and Reversal
Drugs
COR LOE
Recommendations
1 B-NR 1. In patients with AF receiving dabigatran who develop
life-threatening bleeding, treatment with idarucizumab is
recommended to rapidly reverse dabigatran's anticoagulation
effect.
2a C-LD 2. In patients with AF receiving dabigatran who develop life-
threatening bleeding, treatment with activated prothrombin
complex concentrate (PCC) is reasonable to reverse dabigatran's
anticoagulation effect if idarucizumab is not available.
1 B-NR* 3. In patients with AF receiving factor Xa inhibitors who
develop life-threatening bleeding, treatment with either
andexanet alfa (apixaban or rivaroxaban*, edoxaban
†
) or
4-factor prothrombin complex concentrate# is recommended
to rapidly reverse factor Xa inhibitor's anticoagulation effect.
C-LD
†
1 A 4. In patients with AF receiving warfarin who develop life-
threatening bleeding, treatment with 4-factor prothrombin
complex concentrate (if available) in addition to intravenous (IV)
vitamin K is recommended to rapidly achieve INR correction
over fresh frozen plasma and intravenous vitamin K treatment.
2b B-NR 5. In patients with AF who develop major GI bleeding,
resumption of oral anticoagulation therapy may be
reasonable after correction of reversible causes of bleeding
and reassessment of its long-term benefits and risks with a
multidisciplinary team approach during SDM with patients.
* B-NR LOE applies to data on apixaban or rivaroxaban.
†
C-LD LOE applies to data on edoxaban.
