Comparison of low- and high-dose recombinant activated factor VII for postcardiac surgical bleeding

Comparison of Low Dose Recombinant Factor VIIa and 4-Factor Prothrombin Complex Concentrate for Treatment of Bleeding Related to Cardiac Surgery

Background: Recombinant factor VIIa (rFVIIa) and prothrombin concentrate complex (PCC) are used for uncontrolled bleeding in cardiac surgery (CS), however, there are limited direct comparisons of these agents. Objective: To evaluate the efficacy and safety of rFVIIa and PCC in CS related bleeding. Methods: This retrospective study included adult CS patients who received either low dose rFVIIa (<30 mcg/kg) or 4-factor PCC. The primary outcome was transfusion requirements of packed red blood cells (pRBC) within 6 hours of factor administration. Secondary efficacy outcomes included transfusion requirements 0-18 hours, doses of additional factor product, thrombotic events, and acute kidney injury (AKI). Results: A total of 179 patients were included (n = 78 rFVIIa; n = 101 PCC). Of patients who received blood products, there was no difference in the requirement of pRBCs within 6 hours (73.8 vs 68.9%, P = .5359) or in the median amount of pRBC transfused (500 mL vs 640 mL, P = .0723) in the rFVIIa and PCC groups respectively. Patients in the PCC group were more likely to require additional factor products (24.4% vs 47.5%, P = .0015), develop AKI (12.8% vs 25.7%, P = .0325), have longer ICU lengths of stay [2 (IQR 1-5) vs 4 (IQR 2-6), P = .0487] and greater in-hospital mortality (2.6% vs 10.9%, P = .033). There was no difference in thrombotic events. Conclusion: Although, there was no difference in pRBC transfusion requirements between PCC and rFVIIa, more patients in the PCC group required additional factor products and had increased adverse effects. Further comparisons of PCC and rFVIIa are warranted.

Very low-dose recombinant Factor VIIa administration for cardiac surgical bleeding reduces red blood cell transfusions and renal risk: a matched cohort study

Outcomes following administration of very-low-dose recombinant activated factor VIIa (vld-rFVIIa) for cardiac surgical bleeding remain debatable. We sought to determine the association of vld-rFVIIa and adverse surgical outcomes. Retrospective, cohort matching of patients undergoing cardiac surgery who received vld-rFVIIa (median 13.02 μg/kg) for perioperative bleeding were matched to cardiac surgical patients who had bleeding and received standard of care for bleeding without Factor VIIa administration. Of the 362 matched patients (182 in each group), patients who received rFVIIa required significantly less red blood cell transfusions [median 3 units (range 0--60, IQR = 4 units) versus 4 units (range 2-34, IQR = 4 units); P = 0.0004], decreased length of hospital stay (median 8 versus 9 days; P = 0.0158) and decreased renal risk (P < 0.0001). Incidence of renal failure, postoperative infection, postoperative thrombosis, prolonged ventilation, total ICU hours and 30-day mortality were not different between the two groups. Vld-rFVIIa for cardiac surgical bleeding was associated with decreased red blood cell transfusion, renal risk and length of hospital stay without increased thromboembolism or mortality when compared to patients who had cardiac surgical bleeding and received standard of care without Factor VIIa.

Use of recombinant activated factor VII for the treatment of perioperative bleeding in noncardiac surgery patients without hemophilia: A systematic review and meta-analysis of randomized controlled trials

PURPOSE

To evaluate the efficacy and safety of perioperative use of recombinant activated factor VII (rFVIIa) in noncardiac patients.

MATERIALS AND METHODS

We searched electronic databases for randomized controlled trials (RCTs) that involved the use of rFVIIa through December 13, 2019 in noncardiac patients without hemophilia. Two investigators extracted the related data and assessed the quality of the included trials.

RESULTS

Eleven RCTs examining 993 perioperative patients were ultimately included. The use of rFVIIa did not decrease all-cause mortality (RR:0.90; 95% CI:0.50,1.64; I² = 0.0%; P = 0.738), shorten the length of ICU (SMD:-0.15; 95% CI:-0.47,0.17; I² = 0.0%; P = 0.346) or hospital (SMD:0.42; 95% CI:-0.05,0.89; I² = 0.0%; P = 0.078) stay, or increase incidence of the thromboembolic events (RR:1.30; 95% CI:0.70,2.41; I² = 0.0%; P = 0.403) among perioperative patients. However, individual RCT analyses showed that the use of rFVIIa could reduce the volume of blood loss (including prostatic cancer, severe acute pancreatitis (SAP), and spinal disease) and the transfusion of RBCs (including prostatic cancer, SAP, and spinal disease) and FFP (SAP) in a subset of perioperative patients. Publication bias was not present.

CONCLUSIONS

For perioperative hemorrhagic patients, rFVIIa-based hemostatic therapy showed no effect on mortality, ICU or hospital LOS, or the rate of thromboembolic events, although it appears to decrease blood loss and reduce the need for blood product transfusion in a subset of patients.

Recombinant activated factor VII is associated with postoperative thromboembolic adverse events in bleeding after coronary surgery

OBJECTIVES

To evaluate the impact of recombinant activated factor VII (rFVIIa) administration on thromboembolic adverse events (TAEs) in coronary artery bypass grafting (CABG) surgery patients showing postoperative bleeding.

METHODS

From January 2004 to May 2015, 180 CABG surgery patients with postoperative bleeding were included in the study. All patients were managed conservatively and 81 (45%) also received rFVIIa.

RESULTS

Ten patients developed new TAEs (5.6%), 15 (8.3%) were re-explored, 4 (2.2%) had postoperative dialysis and 6 (3.3%) died by day 30 postoperation. Among those with TAEs, 7 experienced cerebrovascular accidents, 2 had myocardial infarction and 1 had pulmonary embolism. A multivariable regression model confirmed rFVIIa as the only independent factor associated with the development of TAEs (odds ratio 6.19, 95% confidence interval 1.197-31.996; P = 0.0296). Fifteen (8.3%) patients were re-explored for bleeding according to our management protocol. No variables to predict the need for re-exploration were identified by the regression model. Chest tube output was statistically significantly lower in patients who received rFVIIa from 3 h [1.9 (Q1-Q3 1.7-2.1) ml/kg/h vs 3.2 (Q1-Q3 3-3.4) ml/kg/h, P = 0.000] through to 12 h after admission [0.6 (Q1-Q3 0.5-0.6) ml/kg/h vs 0.7 (Q1-Q3 0.6-0.9) ml/kg/h, P = 0.000].

CONCLUSIONS

rFVIIa for the treatment of post-CABG bleeding resulted in increased incidence of TAEs in spite of rapid control of bleeding. Hence, rFVIIa should only be used for selected patients and with extreme caution.