Aortic dissection during rivaroxaban therapy: a challenging care

Sir, The recent paper published by Stein et al. highlights the complex management of patients treated with direct oral anticoagulant therapy in emergency contexts. We also encountered a complex challenge in our cardiac intensive care unit: a 65-year-old man (height 191 cm; weight 123 kg) was first hospitalized in a secondary hospital emergency room for Stanford type A aortic dissection associated with a non-compressive, 20-mm thick hemorrhagic pericardial effusion. The patient had been treated with rivaroxaban 20 mg once daily for chronic atrial fibrillation and metoprolol 200 mg once daily. He had history of pulmonary embolism. On admission, hemoglobin was 16.6 g/dl, platelets 155 × 10/l prothrombin time 31% (reference range 70–130%), international normalized ratio 2.8, activated partial thromboplastin time 41 s, and creatinine clearance was 69 ml/min/1.73m. During transfer to emergency room, the patient received fluid therapy and acetyl salicylic acid 250 mg intravenously because myocardial infarction was suspected. Rivaroxaban was stopped on admission. On the night following admission, the patient was transferred from the secondary hospital to a cardiac intensive care unit. A surgical intervention was planned but delayed because rivaroxaban activity was 144 ng/ml, higher than the max required (<30 ng/ml). The patient received prothrombin complex concentrate (25 UI/kg, 120 ml). In the morning, he had cardiorespiratory arrest with cardiac tamponade and asystole. He received resuscitation measures with tracheal intubation, cardiac massage, and adrenalin. A pericardial drainage was attempted, but this was unsuccessful, and the patient died. In this case of pericardial effusion in an aortic dissection context, management was complex and delayed because of a residual but significant rivaroxaban activity. Given the absence of specific treatment option and especially antidote to reverse the anticoagulant effects of direct oral anticoagulant therapy, challenging in emergency circumstance, particularly in high mortality rate disease, is highly problematic. In this context, in cases of aneurysm or aortic dissection history, when anticoagulation is required, vitamin K antagonist should perhaps be preferred. Moreover, these case reports illustrate the need for producing an effective antidote as soon as possible.