Factor Xa (FXa) inhibitors are direct oral anticoagulants (DOACs) and safe and effective alternatives to warfarin in preventing stroke in patients with atrial fibrillation and treating venous thrombosis [
1]. Apixaban (Eliquis©; Bristol-Myers Squibb/Pfizer EEIG, Uxbridge, United Kingdom) is an oral, direct-acting FXa inhibitor with a half-life of approximately 12 hours. The treatment is less complicated than warfarin treatment, as it consists of a fixed dose which does not require monitoring [
2]. Because of the convenience and proven efficacy, the prescription rate of DOACs is increasing worldwide [
3]. Consequently, the number of patients who are anticoagulated with DOACs and need emergency surgery for coexisting conditions increases accordingly. However, reversal of the effect of FXa inhibitors is still a matter of debate. The antidote andexanet alfa has shown promising results in clinical studies, but it is still not commercially available [
4]. Furthermore, this antidote is not a good option for reversing the FXa inhibitor effect before cardiovascular surgery, as it is unspecific and reverses all FX inhibitors, including heparinization, that are required during cardiopulmonary bypass. Guidelines providing a strategy to manage bleeding complications or emergency surgery in FXa inhibitor-treated patients are not conclusive and suggest 4-factor prothrombin complex concentrate (4-PCC) or activated prothrombin complex concentrate (aPCC) as reversal agents [
5]. 4-PCC contains factor II, VII, IX, and X in their inactive zymogen forms and is used to reverse the anticoagulation effect of warfarin. aPCC is used to treat hemophiliacs with inhibitor and contains activated FVII in addition to factor II, IX, and X. The documentation of the ability of these reversal agents to reverse the anticoagulation of FXa inhibitors is limited, and apart from one cohort study evaluating the effect of 4-PCC as reversal agent in apixaban-treated patients undergoing major bleeding [
6], only animal studies,
in vitro studies, and case reports exist [
7‐
12]. In the following case series we present three patients in whom aPCC was used to reverse the anticoagulation effect of apixaban before emergency cardiovascular surgery. The reversal effect was assessed both clinically by the surgeon and by coagulation tests.