Use of Recombinant Activated Factor VII for Bleeding Following Operations Requiring Cardiopulmonary Bypass

Use of Factor VIIa and Anti-inhibitor Coagulant Complex in Pediatric Cardiac Surgery Patients

OBJECTIVES

Postoperative bleeding is a common cause of morbidity and mortality in cardiac patients who undergo cardiopulmonary bypass (CPB). Pediatric patients are especially at risk for adverse effects of surgery and CPB on the coagulation system. This can result in bleeding, transfusions, and poor outcomes. Excessive bleeding unresponsive to blood products can warrant the off-label use of recombinant activated clotting factor VIIa (rFVIIa) and/or anti-inhibitor coagulant complex (FEIBA). Several studies have shown the utility in these agents off-label in patients who have undergone cardiac bypass surgery with acute bleeding episodes that are refractory to blood products. However, data regarding use of these agents in pediatrics are sparse. The purpose of this study is to report the use of rFVIIa and FEIBA in pediatric cardiac surgery patients in our institution.

METHODS

This was a retrospective chart review of pediatric cardiothoracic surgery patients who received rFVIIa or FEIBA at Children's Healthcare of Atlanta during the study period.

RESULTS

Thirty-three patients received rFVIIa and 9 patients received FEIBA either intraoperatively or postoperatively for bleeding related to the cardiac procedure. Approximately 13% of rFVIIa patients and 55% of FEIBA patients required repeat doses. There were decreases for all blood products administered after rFVIIa and FEIBA were given. However, the doses used did not correlate with either positive or negative outcomes. Seventeen percent (n = 7) of rFVIIa patients experienced a thrombus and 22% (n = 2) of FEIBA patients experienced a thrombus.

CONCLUSIONS

Both rFVIIa and FEIBA reduced blood product usage in pediatric patients following cardiac procedures.

Recombinant activated factor VII (rFVIIa) in refractory haemorrhage for non-haemophiliacs: an eleven-year single-centre experience

Background

Massive bleeding is one of the commonest salvageable causes of death. The search for an ideal haemostatic agent during massive bleeding is still ongoing. One of the novel haemostatic medications is recombinant activated factor VII (rFVIIa). To date, the usage of rFVIIa during massive haemorrhage among non-haemophiliac patients remains off-label. The aim of this study is to report our experience in using rFVIIa to treat refractory bleeding.

Methods

Medical records of all patients treated with rFVIIa for massive bleeding over an eleven-year period in a single institution were recorded. Treatment indications, 24-h and 30-day mortality, changes in transfusion needs and coagulation profiles after rFVIIa administration were analysed.

Results

rFVIIa were administered in 76 patients. Of these, 41 (53.9%) were non-surgical bleeding, followed by 22 patients (28.9%) with trauma, other surgery bleedings in 9 patients (11.8%) and 4 patients (5.4%) with peripartum haemorrhage. Total survival rate was 78.9% within 24 h and 44.7% over 30 days. Among all these patients who had received rFVIIa due to life-threatening haemorrhage, blood and blood product requirements were significantly reduced (P < 0.001), and the coagulation profiles improved significantly (P < 0.05). Two patients with preexisting thromboembolism were given rFVIIa due to intractable bleeding, both survived. No thromboembolic events were reported after the administration of rFVIIa.

Conclusions

rFVIIa significantly improved coagulation parameters and reduced blood product requirements during refractory haemorrhage. Additionally, usage of rFVIIa in trauma and peripartum haemorrhage patients yield better outcomes than other groups of patients. However, the overall mortality rate remained high.

Impact on postoperative bleeding and cost of recombinant activated factor VII in patients undergoing heart transplantation

Background:

Cardiac transplantation can be complicated by refractory hemorrhage particularly in cases where explantation of a ventricular assist device is necessary. Recombinant activated factor VII (rFVIIa) has been used to treat refractory bleeding in cardiac surgery patients, but little information is available on its efficacy or cost in heart transplant patients.

Methods:

Patients who had orthotopic heart transplantation between January 2009 and December 2014 at a single center were reviewed. Postoperative bleeding and the total costs of hemostatic therapies were compared between patients who received rFVIIa and those who did not. Propensity scores were created and used to control for the likelihood of receiving rFVIIa in order to reduce bias in our risk estimates.

Results:

Seventy-six patients underwent heart transplantation during the study period. Twenty-one patients (27.6%) received rFVIIa for refractory intraoperative bleeding. There was no difference in postoperative red blood cell transfusion, chest tube output, or surgical re-exploration between patients who received rFVIIa and those who did not, even after adjusting with the propensity score (P = 0.94, P = 0.60, and P = 0.10, respectively). The total cost for hemostatic therapies was significantly higher in the rFVIIa group (median $10,819 vs. $1,985; P < 0.0001). Subgroup analysis of patients who underwent redo-sternotomy with left ventricular assist device explantation did not show any benefit for rFVIIa either.

Conclusions:

In this relatively small cohort, rFVIIa use was not associated with decreased postoperative bleeding in patients undergoing heart transplantation; however, it led to significantly higher cost.

Controlling intrathoracic hemorrhage on ECMO: help from Factor VIIa and Virchow

Objective:

Thoracentesis with chest tube placement is often needed to decompress a clinically significant pneumothorax or pleural effusion. The risks of such a procedure may be considered too great to perform on a systemically anticoagulated patient supported by extracorporeal membrane oxygenation (ECMO).

Results:

An 8-year-old child with respiratory failure due to necrotizing pneumonia and autoimmune vasculitis, on veno-venous ECMO, developed a severe tension pneumothorax that required emergent decompression with a chest tube. Post-procedure, the patient developed a hemothorax that was approaching non-sustainability. We developed a strategy based on Virchow’s triad to favor homeostasis in the patient while avoiding thrombosis in the ECMO circuit. We employed selective lung ventilation, passive pleural drainage, high flow ECMO, and aggressive coagulation cascade control, including the use of aminocaproic acid and activated factor VIIa. Following this strategy, the hemorrhage was controlled and, later, the patient was able to successfully come off ECMO.

Conclusions:

With careful coagulation cascade manipulation, complete lung rest for the affected lung, control of ECMO blood flow, and prudent hemothorax drainage, we were able to facilitate hemostasis that was required for the successful recovery of our patient while avoiding critical ECMO circuit thrombosis. Even with today’s highly advanced medical technologies, centuries-old basic medical principles can still assist in the care of our sickest and most complex patients. Chest tube placement while on ECMO is rare and, although necessary, may be a risky procedure. With precise coagulation control, it can be a successful procedure on ECMO.

Adverse drug events associated with disorders of coagulation

Disorders of coagulation are common adverse drug events encountered in critically ill patients and present a serious concern for intensive care unit (ICU) clinicians. Dosing strategies for medications used in the ICU are typically developed for use in noncritically ill patients and, therefore, do not account for the altered pharmacokinetic and pharmacodynamic properties encountered in the critically ill as well as the increased potential for drug-drug interactions, given the far greater number of medications ordered. This substantially increases the risk for coagulation-related adverse reactions, such as a bleeding or prothrombotic events. Although many medications used in the ICU have the potential to cause coagulation disorders, the exact incidence will vary based on the specific medication, dose, concomitant drug therapy, ICU setting, and patient-specific comorbidities. Clinicians must strongly consider these factors when evaluating the risk/benefit ratio for a particular therapy. This review surveys recent literature documenting the risk for adverse drug reactions specific to bleeding and/or clotting with commonly used medications in the ICU.

Guideline on antiplatelet and anticoagulation management in cardiac surgery

This document presents a professional view of evidence-based recommendations around the issues of antiplatelet and anticoagulation management in cardiac surgery. It was prepared by the Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery (EACTS). We review the following topics: evidence for aspirin, clopidogrel and warfarin cessation prior to cardiac surgery; perioperative interventions to reduce bleeding including the use of aprotinin and tranexamic acid; the use of thromboelastography to guide blood product usage; protamine reversal of heparin; the use of factor VIIa to control severe bleeding; anticoagulation after mechanical, tissue valve replacement and mitral valve repair; the use of antiplatelets and clopidogrel after cardiac surgery to improve graft patency and reduce thromboembolic complications and thromboprophylaxis in the postoperative period. This guideline is subject to continuous informal review, and when new evidence becomes available. The formal review date will be at 5 years from publication (September 2013).

Successful Graft Patency After Factor VIIa Use for Bleeding in Coronary Artery Surgery

There is a growing literature regarding the use of recombinant activated factor VII (rFVIIa) (NovoSeven, NovoNordisk, Copenhagen, Denmark) to control refractory hemorrhage after cardiopulmonary bypass in cardiac surgery. This supporting evidence is mostly documented as case reports on patients, of which only six involve coronary artery grafting. We present our experience of a patient undergoing coronary artery bypass grafting, who suffered an anaphylactic reaction to protamine preventing safe reversal of systemic heparinization. Subsequent management of postoperative bleeding was successfully achieved only after rFVIIa administration.

Recombinant factor seven therapy for postoperative bleeding in neonatal and pediatric cardiac surgery

BACKGROUND

Severe bleeding is a major complication in the postoperative pediatric cardiac surgery patients. We evaluated the efficacy and safety of recombinant factor seven (rFVIIa) therapy in this patient population.

METHODS

A retrospective unmatched case-control study for the previous five years in a single institution was undertaken. Patients with severe bleeding treated with rFVIIa therapy (study group) were compared with patients treated with blood products only (control group) using analysis of variance. Mediastinal bleeding, blood products transfusion, and coagulation studies before and six hours after the first dose of rFVIIa therapy were analyzed using the Student paired t test. The dose, frequency, and side-effects of rFVIIa therapy were studied.

RESULTS

Forty-six patients with severe bleeding were studied. Twenty-three of 24 patients in the study group, including 12 patients placed on extracorporeal membrane oxygenation (ECMO), responded to rFVIIa therapy (mean dose 43 +/- 22.9 microg/kg/dose). There was significant reduction in chest tube drainage (from 52.3 +/- 36.1 mL/kg/hour to 18.8 +/- 20.9 mL/kg/hour, p = 0.0003) along with significant reduction of blood products transfusion (p < 0.001) in the study group patients as compared with control group patients. One patient who failed to respond had surgical bleeding. Two patients developed major thrombotic complications that included clots in the ECMO circuit and thrombosis at bleeding arterial line site resulting in limb ischemia. Four additional patients in the study group developed mediastinal clots. Overall, 25% of patients developed thrombosis after rFVIIa therapy.

CONCLUSIONS

The rFVIIa therapy seems to be an effective treatment for severe bleeding in postoperative pediatric cardiac surgery patients in the absence of surgical bleeding. It must be judiciously used in patients bleeding from multiple sites or having preexistent clots in the ECMO circuit to prevent major thrombotic complications.

Use of activated recombinant factor VII for severe coagulopathy post ventricular assist device or orthotopic heart transplant

BACKGROUND

Ventricular assist devices(VAD) implantation/removal is a complex surgical procedure with perioperative bleeding complications occurring in nearly half of the cases. Recombinant activated factor VII (rFVIIa) has been used off-label to control severe hemorrhage in surgery and trauma. We report here our experience with rFVIIa as a rescue therapy to achieve hemostasis in patients undergoing orthotopic heart transplant (OHT) and/or VAD implantation.

METHODS

A retrospective review was conducted from Jan 03 to Aug 05 for patients who received rFVIIa for the management of intractable bleeding unresponsive to standard hemostatic blood component therapy. Blood loss and the quantity of blood products, prior to, and for at least 12 hours after, administration of rFVIIa were recorded.

RESULTS

Mean patient age was 53, (38-64 yrs), mean dose of rFVIIa administered was 78.3 microg/kg (24-189 microg/kg) in 1-3 doses. All patients received the drug either intraoperatively or within 6 hours of arrival in ICU. Mean transfusion requirements and blood loss were significantly reduced after rFVIIa administration (PRBC's; 16.9 +/- 13.3 to 7.1 +/- 6.9 units, FFP; 13.1 +/- 8.2 to 4.1 +/- 4.9 units, platelets; 4.0 +/- 2.8 to 2.1 +/- 2.2 units, p < 0.04 for all). 5 patients expired including 3 with thromboembolic cause. One patient developed a lower extremity arterial thrombus, and another deep vein thrombosis.

CONCLUSION

In this review, there was a significant decrease in transfusion requirement and blood loss after rFVIIa administration. Although, 5/17 developed thromboembolic complications, these patients may have been at higher risk based on the multiple modality therapy used to manage intractable bleeding. Nevertheless, the exact role of rFVIIa with respect to development of thromboembolic complications cannot be clearly determined. Further investigation is needed to determine rFVIIa's safety and its effectiveness in improving postoperative morbidity and mortality.

Coagulopathy After Cardiopulmonary Bypass in Jehovah’s Witness Patients: Management of Two Cases Using Fractionated Components and Factor VIIa

BACKGROUND

Changes in the Jehovah's Witness (JW) blood refusal policy now give members the personal choice to accept certain processed fractions of blood, such as factor concentrates and cryoprecipitate.

METHODS

Two JW patients undergoing complex aortic surgery who developed severe microvascular bleeding after prolonged use of cardiopulmonary bypass were treated with recombinant activated factor VII, cryoprecipitate, and antithrombin concentrate.

RESULTS

Cardiopulmonary bypass-induced coagulopathy was successfully treated, allowing chest closure without evidence of thrombotic complications.

CONCLUSIONS

Processed blood fractions can be a valuable adjuvant to drugs when treating bleeding in JW patients.

Recombinant Activated Factor VII in Cardiac Surgery: A Systematic Review

Postoperative hemorrhage is a common complication in cardiac surgery, and it is associated with a considerable increase in morbidity, mortality, and cost. Recombinant activated factor VII (rFVIIa) is an emerging hemostatic agent, increasingly used in cardiac surgery. This article systematically reviews the evidence regarding the efficacy, safety, and cost of rFVIIa in this setting. Although definitive evidence from randomized controlled trials is lacking, the use of rFVIIa in patients experiencing refractory postoperative hemorrhage seems promising and relatively safe. However further research is required to definitively establish its clinical utility in the postoperative cardiac patient.

Recommendations on the use of recombinant activated factor VII as an adjunctive treatment for massive bleeding--a European perspective

Introduction

Our aim was to develop consensus guidelines for use of recombinant activated factor VII (rFVIIa) in massive hemorrhage.

Methods

A guidelines committee derived the recommendations using clinical trial and case series data identified through searches of available databases. Guidelines were graded on a scale of A to E (with A being the highest) according to the strength of evidence available. Consensus was sought among the committee members for each recommendation.

Results

A recommendation for the use of rFVIIa in blunt trauma was made (grade B). rFVIIa might also be beneficial in post-partum hemorrhage (grade E), uncontrolled bleeding in surgical patients (grade E), and bleeding after cardiac surgery (grade D). rFVIIa could not be recommended for use in the following: in penetrating trauma (grade B); prophylactically in elective surgery (grade A) or liver surgery (grade B); or in bleeding episodes in patients with Child–Pugh A cirrhosis (grade B). Efficacy of rFVIIa was considered uncertain in bleeding episodes in patients with Child–Pugh B and C cirrhosis (grade C). Monitoring of rFVIIa efficacy should be performed visually and by assessment of transfusion requirements (grade E), while thromboembolic adverse events are a cause for concern. rFVIIa should not be administered to patients considered unsalvageable by the treating medical team.

Conclusion

There is a rationale for using rFVIIa to treat massive bleeding in certain indications, but only adjunctively to the surgical control of bleeding once conventional therapies have failed. Lack of data from randomized, controlled clinical trials, and possible publication bias of the case series data, limits the strength of the recommendations that can be made.

Effective Management of Refractory Postcardiotomy Bleeding With the Use of Recombinant Activated Factor VII

BACKGROUND

Severe coagulopathy after cardiovascular surgery may lead to intractable bleeding and is associated with increased mortality and morbidity. Recent studies have suggested that recombinant activated factor VII (rFVIIa) may play a role in decreasing postoperative bleeding. Herein we report our experience with the off-label use of rFVIIa in patients with refractory postcardiotomy bleeding.

METHODS

From June 2003 to December 2005, 17 patients (mean age, 65 +/- 18 years) received rFVIIa for refractory bleeding after cardiac surgery. Preoperative risk factors for bleeding included reoperation (n = 7), emergency surgery (n = 7), and renal or hepatic failure (n = 3). Surgical procedures were aortic surgery (n = 7), complex valve operations (n = 7), coronary artery bypass grafting (n = 2), and cardiac tumor resection (n = 1).

RESULTS

The average dose of rFVIIa was 103.1 +/- 30.2 microg/kg. After the administration of rFVIIa the blood loss was reduced and chest tube output decreased from an average of 300 mL/h to 60 mL/h (p = 0.024). Coagulation variables normalized (mean prothrombin time, 18 +/- 7 versus 14 +/- 3 seconds; p = 0.03; mean partial thromboplastin time, 94 +/- 50 versus 49 +/- 14 seconds; p = 0.02), and the need for blood products was significantly reduced. Only 1 patient required mediastinal reexploration. No thromboembolic complications occurred during hospitalization.

CONCLUSIONS

This study suggests that rFVIIa is safe and efficacious in the management of refractory postcardiotomy bleeding. The use of rFVIIa is associated with reduced blood loss, rapid improvement of coagulation variables, and decreased need for blood products. Further studies are necessary to determine the safety and efficacy of this new hemostatic agent and its precise role in the treatment of severe postoperative coagulopathy.

Confirmed graft flow following use of recombinant factor VIIa in coronary artery bypass grafting: a case report and literature review

We present our experience of a unique opportunity to survey coronary artery bypass graft (CABG) patency following the administration of recombinant factor VIIa in the early postoperative period. A review of the published literature on use of this medication in cardiothoracic surgery, specifically CABG, is included.

Efficacy of recombinant activated factor VII in unselected patients with uncontrolled haemorrhage: a single centre experience

Recombinant activated factor VII (rFVIIa /Novoseven) has been used in a wide variety of circumstances as a treatment for uncontrolled bleeding. We present a retrospective report of the use of rFVIIa in 40 consecutive patients without inherited bleeding disorders in a single centre. Twenty-one (68%) of the 31 patients whose response to rFVIIa was documented showed a reduction or cessation in bleeding; in nine patients (29%) bleeding was unchanged and in one patient (3%) bleeding increased despite rFVIIa. One person suffered a thrombotic stroke after rFVIIa treatment. There were no other adverse events directly attributable to rFVIIa. Twenty-four patients (60%) died during the hospital admission in which the rFVIIa was administered. Twelve patients (30%) who received rFVIIa had bleeding secondary to haematological malignancy and 21 patients (53%) had bleeding complicating a surgical procedure. There were 11 deaths (92%) in the haematological malignancy group and 10 deaths (48%) in the surgical group. Patients with haematological malignancy received a significantly greater median number of doses of rFVIIa than patients with surgical bleeding complications (three versus one dose, P = 0.04). We conclude that rFVIIa can be used safely in uncontrolled haemorrhage and the majority of patients show a response.

Efficacy of desmopressin in preventing hemorrhagic complications in a patient with Marfan syndrome undergoing cardiac surgery

In this case report, we describe the successful use of desmopressin as prophylaxis against hemorrhage in a patient with a bleeding tendency associated with Marfan syndrome and a platelet function defect undergoing cardiovascular surgery.