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Olivia Kreidler
Medical University of South Carolina
Charleston, SC
Disclosure information not submitted.
Loren Francis, MD
Department of Anesthesiology
Medical University of South Carolina, United States
Disclosure information not submitted.
Caroline Perez, PharmD, BCPS
Solid Organ Transplant Clinical Pharmacy Specialist
Medical University of South Carolina, United States
Disclosure information not submitted.
Lucas Witer, MD
Department of Cardiothoracic Surgery
Medical University of South Carolina, United States
Disclosure information not submitted.
Jaclyn Hawn, PharmD, BCCCP
Cardiovascular ICU Clinical Pharmacy Specialist
Medical University of South Carolina, United States
Disclosure information not submitted.
Title: Evaluation of Prothrombin Complex Concentrate for Warfarin Reversal Prior to Heart Transplant
Introduction: Prior to heart transplant, patients may be anticoagulated with warfarin, increasing their risk of perioperative complications and may require warfarin reversal. The optimal dose of 4-factor prothrombin complex concentrate (4F-PCC) to reverse warfarin prior to transplant has not yet been established. The aim of this project was to evaluate the institutional change in 4F-PCC dosing protocol for warfarin reversal prior to heart transplant to determine the impact on effectiveness and safety.
Methods: This was a retrospective, cohort study evaluating patients who underwent heart transplantation before and after implementation of a 4F-PCC preoperative warfarin reversal protocol at a large academic medical center. Included subjects were >18 years old on therapeutic anticoagulation with warfarin who underwent heart transplantation between April 2015 and June 2021. The primary endpoint was resolution of international normalized ratio (INR) to < 1.5. Secondary endpoints included utilization of blood products, thromboembolic events, and reoperation for bleeding.
Results: A total of 40 patients were included in the primary analysis, with 28 patients in the pre-protocol group and 12 patients in the post-protocol group. Baseline characteristics were similar between the two groups. Median dose of 4F-PCC was 24.1 units/kg and 15.5 units/kg in the pre and post-protocol groups, respectively. The median INR before PCC administration was 1.82 and 2.30 in the pre and post-protocol groups. After PCC administration, the median INR was 1.43 in the pre-protocol group and 1.46 in the post-protocol group. Patients in the post-protocol group were administered fewer blood products from the time of surgery through post operation day two (20.3 units vs 41.8 units), had lower incidence of thromboembolic events (0% vs 14.3%), and more frequently required reoperation due to bleeding (50% vs 10.7%).
Conclusions: Implementation of a low-dose 4F-PCC protocol to reverse warfarin in patients undergoing heart transplantation resulted in similar resolutions of INR and improved safety.